UC  SOUTHERN  REGIONAL  LIBRARY  FACILITY 


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LECTUEES   ON   THE 


DIAGNOSIS  OF  ABDOMIlfAL 
TUMORS 


DELIVERED  TO  THE  POST-GRADUATE  CLASS 
JOHNS  HOPKINS  UNIVERSITY,  1893 


BY 


WILLIAM   OSLEE,  M.D. 

PROFESSOR  OF  MEDICINE,   JOHNS  HOPKINS  UNIVERSITY 
PHYSICIAN-IN-CHIEF,  JOHNS  HOPKINS  HOSPITAL,  BALTIUORB 


REPRINTED  FROM 
TEE  NEW   YORK  MEDICAL  JOURNAL,  1894 


NEW    YORK 
D.    APPLETON   AND    COMPANY 

190I 


Copyright,  1894, 
By  D.  APPLETON  AND  COMPANY. 


900 

0  ^^c  I 

1 101 


"  The  sources  to  which  we  turn  for  evidence  respecting 
the  existence  and  nature  of  abdominal  tumors  are :  the 
form  and  appearance  presented  to  the  eye ;  the  form  still 
further  discovered  by  the  touch  ;  the  resistance  ascer- 
tained by  pressure ;  the  sounds  elicited  by  percussion ; 
and,  in  a  few  instances,  the  sounds  perceptible  to  the  ear, 
either  alone  or  by  the  aid  of  the  stethoscope  ;  and  besides 
these  local  and  physical  signs,  we  look  to  the  general  con- 
dition of  the  system,  and  of  the  various  excretions,  as  ren- 
dering us  most  important  assistance,  and  being  frequently 
indispensable  toward  the  formation  of  a  tolerably  correct 
diagnosis." — (Richard  Bright,  On  Abdominal  Tumors.) 


CONTENTS. 


LKCTURB  PAGE 

I.  Tumors  of  the  Stomach 1 

I.  Tumor  formed  by  Dilated  Stomach 2 

II.  Tumor  formed  by  Contracted  Stomach   ....  31 

II.  Nodular  and  Massive  Tumors  of  the  Stomach         ...  35 

(a)  Tumors  of  the  Pyloric  Region 36 

(i)  Tumors  op  the  Body  of  the  Stomach       ....  52 

(c)  Massive  Tumors  of  the  Stomach 57 

III.  Tumors  of  the  Liver 67 

I.  Tumor  formed  by  the  Liver  itself 68 

II.  Abscess 70 

III.  Syphilis 81 

IV.  Cancer 88 

IV.  Tumors  of  the  Gall  Bladder      ..'....  99 

(a)  Dilated  Gall  Bladder 99 

(b)  Ill-defined  Nodular  Tumors  at  Liver  Edge  .        .        .112 

(c)  Cancer  of  the  Gall  Bladder 118 

V.  Miscellaneous  Tumors 124 

I.  Tumors  of  the  Intestine 124 

II.  Omental  Tumors 135 

III.  Tumors  of  the  Pancreas 137 

IV.  Miscellaneous  Tumors         .        .        .       '.        .        .        .  142 

(a)  Cyst  of  Mesentery 142 

(6)  Multiple  Tumor  Masses  in  Abdomen       .        .        .  148 

(c)  Uterine  Fibroid 150 

{d)  Sarcoma  of  the  Abdominal  Wall    ....  151 

(e)  Tumors  of  Doubtful  Nature 153 

(/)  Aneurysm  of  the  Aorta 156 

VI.  Tumors  of  the  Kidney 160 

I.  Movable  Kidney 160 

(a)  Errors  in  Diagnosis  op 160 

(6)  Dietl's  Crises  in 165 

II.  Intermittent  Hydronephrosis 170 

III.  Malignant  Disease  op  Kidney 184 

IV.  Tuberculous  Kidney 189 


LECTUEES  ON  THE 

DIAGNOSIS  OF  ABDOMINAL   TUMORS. 


LECTURE  I. 

TUMORS   OF  THE   STOMACH. 

Gentlemen  :  I  propose  in  the  following  course  to 
bring  before  you  the  experience  gleaned  during  a  period 
of  twelve  montlis  in  the  cases  of  abdominal  tumor  which 
have  come  before  me  for  diagnosis.  I  have  not  in- 
cluded the  cases  admitted  under  the  care  of  Dr.  Thayer 
(my  first  assistant)  during  my  absence  in  July  and  Au- 
gust, unless  I  had  previously  or  have  afterward  seen 
them.  The  condition  has  been  dictated  at  the  time  of 
examination,  the  diagnosis  made,  when  possible,  and  the 
subsequent  history  of  the  cases  has  been  carefully  fol- 
lowed. I  have  not  included  in  the  list  instances  of 
ascites,  appendicitis,  or  simple  enlargement  of  the  liver 
or  spleen;  only  cases  in  which  a  definite  tumor  existed 
in  connection  with  one  or  other  of  the  abdominal  organs. 
We  shall  take  up  the  cases  in  the  following  order : 
stomach,  of  which  there  were  twenty-four,  liver  and 
appendages,  intestines  and  peritonaeum,  renal,  and  mis- 
cellaneous. 

In  the  diagnosis  of  abdominal  tumors  Bishop  Butler's 
maxim  that  "probability  is  the  rule  of  life  "  is  particularly 
true,  and  the  cocksureness  of  the  clinical  physician,  who 


2  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

formerly  had  to  dread  only  the  mortifying  disclosures  of 
the  post-mortem  room,  is  now  wisely  tempered  when  the 
surgeon  can  so  promptly  and  safely  decide  upon  the  nature 
of  an  obscure  case. 

With  the  methods  of  examination  of  the  stomach 
you  are  all  familiar,  having  frequently  seen  them  ap- 
plied; and  as  elaborate  details  are  available  both  in  the 
text  -  books  on  physical  diagnosis,  and  more  fully  in 
the  recent  special  works  on  diseases  of  the  stomach  by 
Ewald,*  Boas,t  Bouveret,J  Debove,  and  Esmond,*  I  shall 
proceed  at  once  to  the  consideration  of  the  subject  in 
hand. 

Tumors  of  the  stomach  are  formed  (1)  by  the  organ 
itself  in  a  condition  of  abnormal  dilatation  or  contraction ; 
(2)  by  nodular  or  massive  outgrowths  of  its  walls. 

I.  The  Tumor  formed  by  a  Dilated  Stomach. — 
There  were  thirteen  cases  of  dilated  stomach  in  the  series, 
in  ten  of  which  the  organ  itself  formed  a  prominent  tumor 
visible  on  inspection.  These  will  form  the  subject  of  the 
present  lecture.  In  all  of  the  cases  the  existence  of  a 
nodular  pyloric  tumor  was  also  determined.  In  another 
case,  not  considered  here,  the  dilatation  of  the  stomach 
was  caused  by  the  pressure  on  the  duodenum  of  a  tumor 
of  the  colon.  I  will  first  read  to  you  the  histories  of  the 
cases,  sometimes  with  the  comments  dictated  at  the  time 
of  examination,  and  then  make  some  general  remarks  on 
the  diagnosis  of  dilated  stomach.  Though  the  condition 
is  common,  I  am  surprised  that  general  practitioners  so 
frequently  overlook  its  presence,  owing  in  large  measure 
to  the  transgression  of  one  of  the  primary  rules  of  diag- 
nosis, namely,  to  carefully  and  systematically  go  through 

*  Klinik  der  Verdauungskrankheiten.    Dritte  Auflage.    Berlin. 

f  Diagnostih  und  TTierapie  der  Magenkranhheiten.    Theil  ii,  Leipsic. 
X  Traite  des  maladies  de  Vestomac.     Paris. 

*  Traite  des  maladies  de  Vestomac.    Paris. 


TUMORS  OF  THE  STOMACH.  3 

the  routine  of  inspection,  palpation,  percussion,  and  in- 
flation. 

Case  I.  Tumor  caused  by  Dilated  Stomach ;  Nodidar  Tumor 
in  Right  Epigastrium;  Waves  of  Peristalsis. — George  A.,  aged 
thirty-nine,  admitted  September  1st,  complaining  of  pain  in  the 
abdomen  and  vomiting.  Patient  is  a  tailor  by  occupation,  and  has 
used  alcohol  to  excess.  Present  illness  began  last  Christmas  with 
symptoms  of  dyspepsia,  occasional  vomiting,  eructations,  and  pain 
in  the  region  of  the  navel.  The  pain  was  much  worse  after  eating 
and  was  described  as  of  a  gnawing  character.  The  food  very  often 
turned  sour.  Has  never  vomited  any  blood.  Lately  the  attacks 
of  vomiting  have  come  on  at  longer  intervals  and  large  quantities 
of  brownish,  foul-smelling  material  have  been  ejected. 

Present  Condition. — Patient  is  a  medium -sized  man,  much  ema- 
ciated, particularly  in  the  trunk  and  extremities;  there  are  no 
glandular  enlargements.  The  tongue  is  thickly  furred.  The  ab- 
domen is  flat,  somewhat  scaphoid,  but  presents  a  slight  prominence 
above  and  to  the  left  of  the  navel.  At  intervals  of  a  minute  or 
two  there  appears  in  the  epigastrium  and  upper  umbilical  region 
a  prominent  tumor,  the  longest  diameter  transverse,  and  having 
somewhat  the  shape  of  the  stomach.  The  chief  prominence  is  in 
the  left  hypochondrium,  and  the  greater  curve  emerges  beneath 
the  costal  margin  in  the  left  nipple  line,  passes  obliquely  down- 
ward to  about  two  inches  below  th6  level  of  the  navel,  and  then 
turns  upward  and  to  the  right,  reaching  nearly  to  the  ribs.  The 
lesser  curve,  not  so  distinct,  passes  two  inches  from  the  ensiform 
cartilage.  During  the  prominence  of  the  tumor  waves  of  contrac- 
tion pass  from  left  to  right  and  there  is  sometimes  a  well-marked 
depression  separating  the  prominent  masses  to  the  left  and  right  of 
the  middle  line.  During  the  periods  of  contraction  the  masses  are 
firm  and  resistant ;  in  the  intervals  they  almost  completely  disap- 
pear and  the  abdomen  in  these  regions  is  quite  soft.  In  the  right 
parasternal  line,  just  below  the  edge  of  the  liver,  is  a  nodular 
tumor. 

Fig.  1  is  from  a  photograph  taken  during  the  passage  of  the 

waves  of  contraction,  three  of  which  are  plainly  to  be  seen  at  the 

situations  marked  with  the  crosses.     The  letter  /  is  placed  in  the 

depression  separating  the  stomach  into  right  and  left.     After  sev- 
9, 


4  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

eral  attacks  of  vomiting,  and  after  having  the  stomach  thoroughly 
washed  out,  the  distention  was  very  much  less  marked,  and  the 
peristaltic  movements  were  less  frequent.  The  nodular  tumor 
mass  was  then  felt  to  be  very  much  more  in  the  middle  line.     For 


Fig.  1.— From  a  photo^aph  by  Dr.  Hewetson,  showing  undulatorj- waves  of  peristalsis 
in  Case  I.  The  crosses  are  placed  on  the  three  prominent  waves.  The  letter  /  in- 
dicates the  depression  on  the  lesser  curve. 


a  week  or  ten  days  before  his  death  this  patient  had  tetany,  which 
is  not  a  very  uncommon  event  in  dilatation  of  the  stomach.  Death 
occurred  September  26th. 

The  autopsy  showed  at  the  pyloric  extremity  of  the  stomach  a 
crater-like  tumor  mass  eight  by  seven  centimetres,  the  margins 
thick,  elevated,  and  indurated.  Externally  there  was  great  thick- 
ening about  the  pylorus,  with  numerous  nodules  on  the  perito- 
naeum.    At  the  pylorus  the  tumor  was  massed  about  the  orifice, 


TUMORS  OF  THE  STOMACH.  5 

througli  which,  however,  the  little  finger  could  pass.  The  coats  of 
the  stomach  were  enormously  thickened.  Fig.  2,  from  a  photo- 
graph taken  on  the  post-mortem  table,  shows  well  the  dilatation  of 
the  stomach. 

Case  II.  Dilated  Stomach,  forming  a  Prominent  Tumor ;  Hi- 
defined  Flattened  Mass  in  Right  Umbilical  Region. — John  L., 
aged  fifty-eight  years,  seen  with  Dr.   Bryson  Wood,  September 


FiQ.  3.— Carcinoma  of  pylorus,  showing  the  dilatation  of  the  stomaci^  .v 
autopsy.    From  a  photograph  by  Dr.  Hewetson. 


jeared  at 


13th,  complaining  of  indigestion  and  loss  of  weight.  The  patient  is 
a  tall,  large-framed  man,  who  has  lived  a  life  of  unusual  energy 
and  activity,  and  prior  to  1875  had  been  a  hard  drinker. 

His  mother  died  of  some  stomach  trouble,  the  precise  nature  of 
which  he  does  not  know.     With  this  exception,  his  family  history 


6 


THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 


is  good.  He  has  always  had  to  be  a  little  careful  about  eating,  but 
until  within  the  past  six  months  has  had  good  health.  The  pres- 
ent illness  began  with  dyspeptic  symptoms,  eructations  of  gas, 
feelings  of  distress  a  few  hours  after  eating,  and  occasional  vomit- 
ing. The  chief  discomfort  was  at  night,  five  or  six  hours  after  the 
last  meal.  Lately  these  features  have  increased  very  much;  he 
has  not  been  able  to  take  solid  food ;  the  eructations  of  gas  have 
become  very  marked,  and  he  has  had  at  intervals  vomiting  of 
large  quantities  of  liquid  and  undigested  food.  He  has  lost  rapidly 
in  weight,  and  has  fallen  from  a  hundred  and  ninety-five  to  a  hun- 
dred and  forty-two  pounds. 

The  condition  on  examination  was  as  follows:  Large-framed 
man,  not  cachectic-looking,  moderately  emaciated.  The  tongue 
has  a  light  white  fur. 

The  abdomen  is  below  the  level  of  the  costal  margin.     In  the 

upper  zone,  occupying  the  left  epi- 
gastric, the  left  umbilical,  and  the 
left  hypochondriac  regions,  there  is 
an  irregular  swelling  which  at  inter- 
vals shows  waves  of  peristalsis  and 
assumes  a  shape  suggestive  of  a  dis- 
tended stomach,  A  lesser  curvature 
can  be  distinctly  seen  three  finger- 
breadths  from  the  ensiform  carti- 
lage; a  greater  curvature  about  two 
inches  below  the  level  of  the  navel. 
The  most  marked  prominence  is  just 
beneath  the  left  costal  margin.  To 
the  right  the  outline  of  the  swelling 
extends  beyond  the  nipple  line.  The 
contrast  between  the  upper  and  lower 
abdominal  zones  is  very  striking,  and 
the  diagnosis  of  the  condition  could 
be  made  at  a  glance,  as  the  organ  hardened  when  the  waves  of 
peristalsis  passed  over  it. 

On  palpation,  the  abdomen  was  everywhere  soft  and  there  was 
no  tenderness.  During  contraction  the  stomach  was  firm  and  re- 
sistant.    There  was  no  nodular  tumor  to  be  felt,  although  between 


Fig.  3.— Showing:  the  stomach  out- 
lines in  Case  II. 


TUMORS  OF  THE  STOMACH.  7 

the  navel  and  the  right  costal  margin  there  was  a  sense  of  in- 
creased resistance,  particularly  beneath  the  ribs.  The  area  of  liver 
dullness  was  diminished.  There  was  no  enlargement  of  the  super- 
ficial glands. 

The  patient  was  ordered  to  have  the  stomach  washed  out  every 
morning,  and  to  take  a  diet  of  milk  and  egg-white. 

October  17th. — Patient  was  seen  again  to-day  with  Dr.  Salzer, 
partly  with  a  view  of  determining  the  advisability  of  a  Loreta's 
operation.  Since  the  last  note  the  patient  has  improved  consider- 
ably under  the  daily  use  of  the  stomach  tube,  and  he  has  been  able 
to  take  Leube's  beef  extract,  meat  balls,  and  small  quantities  of 
milk  without  discomfort.  He  has  not,  however,  gained  in  weight ; 
still  looks  very  haggard  and  emaciated,  and  says  he  at  times  feels 
very  queer  in  his  head,  as  if  he  would  go  crazy. 

The  abdomen  is  a  little  full  in  the  upper  zone,  and  every  few 
minutes  the  distinct  outline  of  the  stomach  can  be  plainly  seen, 
forming  a  tumor  of  unusual  prominence.  The  stomach  tympany 
can  be  obtained  as  high  as  the  fifth  interspace  in  the  parasternal 
line. 

On  palpation,  there  is  no  thickening  or  nodular  mass  to  be  felt 
in  the  epigastric  region,  nor  on  the  deepest  inspiration  can  any 
mass  be  felt  beneath  the  left  costal  margin.  Just  below  the  limit 
of  the  stomach,  and  to  the  right  of  the  navel,  there  is  an  ill-defined 
flattened  mass,  which  does  not,  however,  feel  like  a  thickened 
pylorus,  nor  is  it  likely  that  the  pylorus  could  be  felt  in  this  situa- 
tion with  the  stomach  tympany  and  the  outline  of  the  stomach 
passing,  as  it  does  to-day,  with  such  distinctness  beneath  the  right 
costal  margin.  It  seems  more  probable  that  the  pylorus  is  covered 
by  the  distended  organ. 

Ocotber  S6th. — Subsequent  to  my  last  visit  the  patient  was  trans- 
ferred by  Dr.  Salzer  to  the  care  of  Dr.  Simon,  who  tells  me  that 
uraemic  symptoms  developed  about  the  23d  and  the  patient  died 
comatose  on  the  25th.     There  was  no  autopsy. 

Case  III.  Dilatation  of  the  Stomach ;  Tumors  in  Epigastric 
and  Right  Hypochondriac  Regions. — A.  P.,  aged  forty-seven  years, 
seen  October  19  th  with  Dr.  Jarrett,  of  Towson,  complaining  of  in- 
digestion and  stomach  trouble.  His  personal  and  family  history 
are  excellent,  though  he  states  that  one  brother  died  of  a  tumor  in 


THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 


the  abdomen.  For  the  past  six  months  he  has  been  in  failing 
health  and  has  had  distress  after  eating,  usually  within  half  an 
hour,  sometimes  as  soon  as  ten  minutes.  The  vomitus  consists  of 
the  food  he  has  taken,  never  any  blood.  He  has  never  vomited 
any  very  large  quantities.  The  pain  is  marked  after  eating  and  be- 
comes more  severe  until  the  contents  of  the  stomach  are  ejected. 
On  several  occasions  he  has  passed  blood  in  the  stools,  but  he 
thinks  this  comes  from  haemorrhoids  which  he  has  had  for  many 
years. 

The  patient  is  a  very  well  built  man,  looks  thin,  but  is  a  little 
sallow,  scarcely  cachectic.     Tongue  is  red,  clean,  and  indented. 

Abdomen. — Walls  thin.  Occupying  the  left  epigastric  region 
there  is  a  large  projection  which  varies  in  shape  and  in  promi- 
nence. Definite  peristalsis  is  to  be 
seen,  but  the  waves  do  not  pass  be- 
yond the  middle  line.  This  bulging 
during  peristalsis  occupies  the  left 
epigastric  and  the  upper  right  quad- 
rant of  the  umbilical  regions. 

On  palpation,  the  abdomen  is 
everywhere  soft,  very  resistant  just 
below  the  ensiform  cartilage  and 
over  the  prominence  above  noted. 
In  the  latter  the  resistance  varies 
with  the  presence  or  abscence  of  the 
peristaltic  waves.  Immediately  be- 
low the  ensiform  cartilage  there  is 
a  definite  ridge-like  swelling  which 
is  superficial,  very  tender,  and  does 
not  extend  entirely  across  the  space 
between  the  costal  margins.  It  has 
a  boardy  hardness.  On  drawing  a  deep  breath  the  fingers  can  be 
placed  directly  above  it  and  it  descends  about  an  inch.  In  the  left 
lumbar  region,  just  below  the  tenth  rib  and  the  adjacent  costal  mar- 
gin, there  is  to  be  felt  a  firm  mass,  extending  seven  centimetres  in 
a  vertical  direction.  Anteriorly  in  reality  it  can  be  felt  within  the 
right  epigastric  region,  and  outward  it  extends  to  nearly  the  mid- 
axillary  line.     On  deep  inspiration  it  descends  and  gives  one  some- 


FiQ.  4.— Showing  the  position  of  the 
tumor  masses  in  Case  III. 


TUMORS  OF  THE  STOMACH.  9 

what  the  impression  of  a  rounded  body,  and  on  bimanual  palpation 
it  is  not  very  movable. 

The  edge  of  the  spleen  is  not  palpable  ;  neither  kidney  can  be 
felt  ;  the  edge  of  the  liver  is  not  palpable  ;  nor  does  there  appear  to 
be  any  definite  enlargement  of  the  organ.  On  inflating  the  stom- 
ach the  prominence  in  the  epigastric  and  umbilical  regions  be- 
comes very  mai'ked  and  its  lower  curve  extends  to  a  little  below  the 
navel.  The  upper  limit  of  stomach  tympany  is  just  at  the  sixth 
rib  in  the  nipple  line.  There  are  no  glandular  enlargements. 
The  patient  became  gradually  worse  and  died  about  Christmas 
time. 

Case  IV.  Dilated  Stomach,  forming  a  Visible  Tumor;  an 
Oblong  Mass  in  the  Right  Epigastric  and  Umbilical  Regions. — 
Annie  D.,  aged  forty-eight  years,  Bohemian,  admitted  October  1st, 
complaining  of  swelling  in  the  abdomen,  pain  in  the  back,  and 
vomiting. 

She  knows  of  no  hereditary  disease  in  her  family.  Her  hus- 
band died  of  tuberculosis. 

Patient  was  always  strong  and  well  ;  she  has  had  three  chil- 
dren. Her  present  trouble  began  eight  months  ago  with  pain  of  a 
dull,  aching  character  in  the  stomach,  and  dyspepsia,  but  until  re- 
cently she  has  had  no  vomiting,  and  has  kept  about  and  at  work 
up  to  a  week  ago,  when  she  began  to  vomit.  Prior  to  this  she 
noticed  that  the  abdomen  was  swollen.  The  vomiting  has  been 
chiefly  after  taking  food,  and  she  has  not  brought  up  any  large 
quantities. 

Present  Condition. — Patient  is  thin,  but  the  emaciation  is  not 
extreme.  The  lips  and  mucous  membranes  are  of  a  fairly  good 
color.  Tongue  is  slightly  furred  with  a  white  coating.  Pulse 
regular  ;  temperature  normal  ;  superficial  glands  not  enlarged. 

The  abdomen  is  prominent,  particularly  in  the  umbilical  and 
left  hypochondriac  regions.  Under  observation  there  occur  in 
these  parts  undulatory  waves  of  peristalsis,  and  the  outlines  of  the 
stomach  become  unusually  distinct,  the  greater  curvature  reaching 
fully  three  inches  below  the  level  of  the  navel,  the  lesser  curvature 
just  above  this  point.  As  the  waves  of  contraction  pass  there  is  a 
vertical  constriction  just  to  the  left  of  the  middle  line.  The  peri- 
stalsis comes  on  spontaneously,  and  any  stimulus,  such  as  flipping 


10 


THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 


with  a  towel  or  even  palpation,  at  once  excites  it.  On  palpation, 
except  during-  the  time  of  the  contraction  referred  to,  the  abdomen 
is  everywhere  soft.    Just  above  and  to  the  right  of  the  navel  there 

is  to  be  felt  an  oblong  mass,  which 
takes  a  direction  upward  and  out- 
ward toward  the  costal  margin.  It 
is  oblong,  slightly  movable,  firm, 
smooth,  and  not  painful. 

On  October  3d  a  test  breakfast 
was  given  at  8  A.  M.  At  nine  o'clock 
the  stomach  tube  was  introduced  and 
about  a  quart  and  a  half  of  very 
sour-smelling,  brownish  material  re- 
moved. Dui'ing  the  passage  of  the 
stomach  pump  the  patient  vomited, 
and  she  felt  very  faint.  The  exami- 
nation for  free  hydrochloric  acid  was 
negative. 

The  patient  left  the  hospital  on 
October  14th  in  much  the  same  con- 
dition, and  has  not  been  heard   of 
since. 
Case  V.    Remarkably  Movable  Tumor  of  Pylorus;  Dilated 
Stomach;  Gastro-enterostomy. — Mary  M.,  aged  fifty-eight  years, 
colored,  admitted  on  October  26th,  complaining  of  pain  in  the  ab- 
domen and  vomiting. 

She  has  been  a  healthy  woman,  married  twelve  years;  has  had 
six  children  and  four  miscarriages.  She  has  always  had  very  good 
health  up  to  the  onset  of  present  illness,  which  began  in  June 
with  burning  feelings  in  the  chest  and  pain  after  eating,  sometimes 
vomiting.  These  symptoms  have  continued  with  variations.  At 
times  she  would  be  better,  and  then  she  would  have  spells  of  belch- 
ing and  vomiting.  She  had  often  vomited  large  quantities  of 
liquid.  She  makes  no  complaint  except  of  the  stomach  symptoms. 
Lately  she  has  been  very  constipated. 

Abdomen. — The  walls  are  very  loose,  flabby,  thrown  into  many 
folds.  In  the  right  hypochondriac  and  right  epigastric  regions 
there  is  a  marked  rounded  prominence,  which  below  extends  to 


Fio.  5.— Showing  the  position  of  the 
tumor  and  the  outlines  of  the 
stomach  in  Case  IV. 


TUMOilS  OF  THE  STOMACH. 


11 


within  two  centimetres  of  the  navel,  and  reaches  nearly  to  the 
middle  line.  It  descends  slightly  with  inspiration.  On  palpation, 
this  proves  to  be  a  solid  mass,  which  can  be  grasped  and  is  freely 
movable.  It  is  irregular,  rounded,  not  reniform,  but  is  smooth  at 
its  upper  and  right  borders,  more  irregular  below  and  to  the  left, 
but  a  definite  hilum  is  not  to  be  felt.  To  the  touch  there  is  con- 
veyed a  sense  of  firm  yet  elastic  resistance,  such  as  is  given  by  a 
solid  organ.  On  px'olongcd  palpation  no  gas  is  felt  passing 
through  it.  It  is  extraordinarily  mobile,  and  can  be  pushed  into 
the  epigastric  region  far  over  into  the  right  hypochondriac  region, 
and  below  into  the  right  lumbar  and  umbilical  regions  to  a  level 
with  the  line  of  the  anterior  superior 
spines.  On  firm  pressure,  the  lower 
margin  can  even  be  forced  into  the 
iliac  region.  The  diagram,  which 
was  mads  with  great  care,  illustrates 
the  various  positions  which  the  mass 
can  be  made  to  assume.  It  can  also 
be  pushed  into  the  right  hypochon- 
driac region,  so  as  to  be  covered  al- 
most completely  by  the  ribs,  and  in 
subsequent  examinations  this  was  not 
infrequently  the  situation  in  which 
it  was  found,  and  from  which  it  could 
only  be  dislocated  by  the  deepest  in- 
spiration or  by  deep  pressure  in  the 
renal  region.  The  mass  is  not  tender 
even  on  firm  pressure.  There  is  dull- 
ness over  it,  but  not  complete  flatness. 
The    patient  notices    that  the   mass 

changes  in  position  as  she  moves  about,  and  when  she  sits  up  it 
moves  far  down  into  the  abdomen,  while  when  on  her  back  it  is 
frequently  beneath  the  right  ribs.  When  this  mass  is  out  from 
beneath  the  right  costal  margin  the  right  kidney  can  not  be  felt, 
nor  on  the  left  side,  on  the  deepest  inspiration,  could  the  kid- 
ney be  palpated.  Behind  there  are  depressions  in  the  renal 
regions. 

The  edge  of  the  liver  can  not  be  felt  ;  the  area  of  splenic  dull- 


FiG.  6. — Showing  the  positions  into 
which  the  tumor  could  be  placed 
in  case  V. 


12  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

ness  is  not  increased  ;  the  edge  can  not  be  reached  even  on  deep 
inspiration. 

A  test  breakfast,  withdrawn  an  hour  and  ten  minutes  after, 
gave  two  hundred  cubic  centimetres  of  fluid  in  the  stomach,  which 
contained  no  free  hydrochloric  acid.  The  stomach  was  inflated 
with  gas,  and  the  outline  of  the  greater  curvature  reached  almost 
to  the  navel.  When  the  gas  was  in  the  stomach,  palpation  of  the 
most  careful  character  gave  no  sensation  of  any  fluid  passing 
through  the  tumor. 

This  patient  came  in  with  a  diagnosis  of  probable  can- 
cer in  the  stomach,  which  the  history  of  repeated  attacks 
of  vomiting  and  progressive  loss  of  weight  and  the  exist- 
ence of  a  tumor  in  the  abdomen  seemed  to  justify.  Ex- 
treme mobility  is  a  feature  of  certain  tumors  of  the  py- 
lorus, as  in  the  specimen  which  I  showed  at  the  Philadelphia 
Pathological  Society  of  solid  tumor  of  the  pylorus,  about 
the  size  of  the  mass  under  consideration,  which  could  be 
moved  readily  into  either  hypochondriac  region,  and  which 
was  sometimes  completely  under  the  ribs  and  out  of  reach. 
The  autopsy  showed  it  to  be  a  tumor  of  the  pylorus.  The 
possibility  of  such  cases  has  to  be  considered  in  speaking 
of  the  nature  of  the  present  one.  Here  the  mass  is  of  un- 
usual mobility,  and  can  be  passed  into  the  renal  region  on 
the  right  side.  It  has  not  a  reniform  shape,  but  it  has  the 
consistence  and  the  resistance  of  the  kidney.  A  point 
very  much  in  favor  of  its  renal  character  is  the  mobility 
downward,  and  the  tumor  of  this  sort  which  can  be  pushed 
up  beneath  the  ribs  and  also  far  down  to  the  iliac  regions 
is  certainly  highly  suggestive  of  floating  kidney.  Another 
important  fact  is  that,  in  a  woman  with  such  a  lax  ab- 
dominal wall,  no  right  kidney  can  be  felt.  The  gastric 
disturbance  and  dilatation  of  the  stomach  present  are  both 
explicable  on  the  view  that  this  tumor  mass  has  compressed 
the  duodenum  and  caused  secondary  dilatation.  Nor  is 
this,  considering  the  history  of  so  many  cases,  inconsistent 


TUMORS  OP   THE  STOMACH.  13 

with,  the  view  that  the  tumor  mass  may  be  really  a  kidney. 
On  the  other  hand,  the  tumor  has  not  the  shape  of  a  kid- 
ney, and  a  distinct  hilum  can  not  be  felt.  No  left  kidney 
can  be  palpated,  and  it  may  be  that  this  is  an  instance  of 
conglomerate  kidney,  such  as  was  found  in  Polk's  cele- 
brated case. 

At  any  rate,  I  have  suggested  to  Dr.  Halsted  that  an 
exploratory  laparotomy  be  made,  and  if  it  is  found  to  be  a 
movable  kidney,  the  organ  can  be  stitched  into  position. 

November  Jfth. — The  patient  has  been  better  for  the  past  few 
days.  She  has  had  her  stomach  washed  out  early  in  the  morning. 
To-day  at  ward  class  a  careful  examination  was  again  made.  The 
tumor  mass  was  evident  just  beneath  the  right  costal  margin,  and 
it  was  difficult  to  displace  it  from  this  point  by  the  deepest  inspira- 
tion ;  but,  on  turning  on  the  left  side,  it  readily  fell  over  toward  the 
umbilicus,  and  had  practically  the  mobility  noted  before.  The 
stomach  was  again  inflated,  and  the  outlines  became  remarkably 
plain.  The  greater  curvature  was  just  about  the  level  of  the  navel, 
somewhat  above  the  level  previously  noted.  The  peristalsis  was 
unusually  distinct. 

5th. — This  morning  at  10.30  Dr.  Halsted  operated,  making  a 
long  vertical  incision  over  the  right  rectus.  When  the  peritonaeum 
was  opened  the  tumor  mass  was  directly  exposed,  and  found  to  be 
a  solid  growth  of  the  anterior  wall  and  lesser  curvature  of  the 
stomach  in  the  pyloric  region.  There  were  no  adhesions;  the 
stomach  was  much  dilated.  He  at  first  intended  to  resect  the  tu- 
mor, but,  on  examining  the  retro-peritoneal  glands,  they  were 
found  to  be  enlarged,  and  it  was  thought  best  to  do  a  gastro-enter- 
ostomy.     The  patient  died  two  days  afterward. 

Case  VI.  Tumor  in  Left  Epigastric  Region;  Dilatation  of 
the  Stomach. — In  consultation  with  Dr.  Barclay  I  saw  to-day,  De- 
cember 6th,  A.  B.,  aged  sixty- four  years,  a  German. 

Patient  had  been  in  failing  health  for  some  months,  and  had 
had  dyspepsia  for  several  years.  He,  however,  kept  about  and  at 
his  work  until  early  in  October,  when  he  consulted  Dr.  Barclay  for 
jaundice,  which  seems  to  have  been  intense  and  to  have  come  on 
suddenly,  not,  however,  with  much  pain  and  not  in  a  way  sug- 


14  THE  DIAGNOSIS   OF  ABDOMINAL   TUMORS. 

gestive  of  gallstones.  He  had  never  had  jaundice  before,  but  had 
one  or  two  attacks  of  pain  resembling  that  of  gallstone  colic.  On 
examination,  the  left  lobe  of  the  liver  was  found  to  be  enlarged  and 
a  tumor  mass  occupied  the  whole  of  the  epigastric  region.  It  was 
tender,  not  fluctuating,  and  the  doctor  regarded  it  as  an  enlarged 
left  lobe  of  the  liver.  He  had  moderate  fever.  After  the  persistence 
of  these  symptoms  for  some  weeks  he  vomited  a  quantity  of  pus, 
the  tumor  mass  gradually  disappeared,  and  the  jaundice  became 
less  intense.  The  gastric  symptoms,  however,  continued  and  he 
began  at  intervals  to  vomit  large  quantities  of  dark-brown  material, 
containing  undigested  remnants  of  food.  The  doctor  has  washed 
out  the  stomach  with  great  relief,  but  he  has  gradually  failed  and 
has  become  more  anaemic. 

Present  Condition.— The  patient  is  fairly  well  nourished;  face 
is  not  especially  emaciated,  and  he  has  not  a  cachectic  look.  There 
is  no  jaundice.  The  temperature  is  normal;  pulse  about  96,  of 
fairly  good  volume;  tongue  is  slightly  furred. 

Abdomen. — Panniculus  is  well  preserved.  The  upper  zone  is 
prominent,  particularly  in  the  left  hypochondriac  region,  and  at 
intervals  a  distinct  hemispherical  prominence  appears  below  the 
left  costal  margin,  and  waves  of  peristalsis  are  seen  passing  from 
left  to  right.  The  prominence  is  noticeable  as  far  as  the  navel,  but 
a  definite  contour  of  the  stomach  is  not  visible.  Midway  between 
the  ensiform  cartilage  and  the  navel  and  a  little  to  the  left  there  is 
a  tumor-like  prominence  which  moves  with  the  descent  of  the 
diaphragm.  On  palpation,  the  abdomen  is  everywhere  soft,  quite 
painless  on  pressure,  and  the  tumor  mass  just  described  is  felt  as  a 
firm,  solid  body  about  five  centimetres  in  vertical  extent  and  about 
six  centimetres  in  transverse  extent.  It  is  entirely  to  the  left  of  the 
middle  line.  It  is  firm,  smooth,  not  painful,  except  on  very  firm 
pressure,  and  is  not  movable.  It  descends  about  four  centimetres 
during  inspiration.  No  gurgling  is  felt  in  it.  Nothing  is  to  be 
felt  to  the  left  of  the  median  line  in  the  pyloric  region.  Splashing 
can  be  readily  obtained,  and  on  percussion  the  stomach  tympany 
extends  to  a  finger's  breadth  above  the  navel.  The  upper  limit  of 
the  liver  dullness  in  the  mammillary  line  is  at  the  seventh  rib,  and 
it  does  not  extend  beyond  the  costal  region.  The  left  lobe  of  the 
liver  is  not  palpable;  the  dullness  is  at  the  juncture  of  the  fifth 


TUMORS  OF  THE  STOMACH.  15 

costal  cartilage  with  the  sternum,  and  extends  three  fingers'  breadth. 
It  can  be  separated  from  the  dullness  over  the  tumor  mass  in  the 
epigastric  region.  The  spleen  is  not  enlarged.  There  are  no  super- 
ficial glandular  enlargements. 

The  patient  had  had  a  severe  attack  of  vomiting  this  morning, 
and  his  stomach  was  not  nearly  so  much  dilated  as  usual.  The 
vomited  matter  which  I  saw  had  the  usual  characters — dark  brown, 
with  frothy  scum.  The  urine  was  somewhat  diminished,  and  he 
complained  very  much  of  thirst. 

Two  points  of  interest  present  themselves  in  this  case, 
which  otherwise  seems  to  have  all  the  characters  of  ordi- 
nary dilatation  of  the  stomach  from  pyloric  obstruction. 
In  the  first  place,  the  nature  of  the  attack  of  severe  jaun- 
dice with  the  tumor  mass  in  the  epigastric  region.  From 
Dr.  Barclay's  account,  there  can  be  no  question  that  the 
patient  vomited  a  large  quantity  of  pus,  and  that  subse- 
quent to  this  the  tumor  disappeared  and  the  jaundice  got 
better.  There  are  two  suggestions  in  this  connection :  that 
there  was  a  large  carcinoma  of  the  stomach,  with  suppura- 
tion at  its  base  and  about  the  tissues  of  the  gastro-hepatic 
omentum,  with  compression  of  the  bile  ducts.  Suppura- 
tion does  occur  at  the  base  of  malignant  growths,  more 
particularly  when  they  form  adhesions  with  adjacent 
organs,  and  I  have  placed  such  instances  on  record;  in- 
deed, there  may  be  a  considerable  collection  of  pus  between 
the  left  lobe  of  the  liver  and  the  stomach.  The  other  sug- 
gestion is  that  the  jaundice  and  enlargement  of  the  left 
lobe  of  the  liver  were  associated  with  gallstones  and  sup- 
puration in  the  region  of  the  ducts,  with  discharge  into 
the  stomach,  and  subsequent  cicatricial  contraction  about 
the  pylorus  and  dilatatio  ventriculi.  The  jaundice,  how- 
ever, would  scarcely  have  disappeared,  and  this  is  not  a 
very  likely  condition.  And,  lastly,  it  is  interesting  to  note 
here  the  situation  of  the  tumor  mass — not  at  all  in  the 
position  usually  felt  in  carcinoma  of  the  pylorus,  but,  as 


16  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

will  have  been  noted  in  the  histories  of  the  other  cases, 
the  tumor  is  extremely  variable  in  position.  Though  in  a 
somewhat  unusual  situation,  it  is  quite  possible  that  this 
really  may  be  a  tumor  mass  causing  the  stenosis  of  the 
pyloric  orifice. 

Dr.  Barclay  writes  me  that  this  patient  died  on  the  29th 
of  December  of  exhaustion.  The  post-mortem  showed  an 
enormously  distended  stomach,  which  covered  the  intes- 
tines like  an  apron.  The  pyloric  orifice  was  surrounded 
by  a  large  mass  of  cancer,  which  so  nearly  occluded  it  that 
only  the  tip  of  the  finger  could  enter.  The  cancer  extended 
also  slightly  into  the  duodenum  and  on  the  posterior  wall 
of  the  stomach,  which  showed  extensive  ulceration.  The 
left  lobe  of  the  liver  was  shrunken  and  showed  soft, 
nodular  masses  breaking  down  into  pus.  The  mesenteric 
glands  were  enlarged  and  cancerous.  The  bile  passages 
and  gall  bladder  were  normal. 

The  post-mortem  does  not  throw  much  light  upon  the 
early  history  of  this  case,  the  symptoms  of  which  came  on 
apparently  with  jaundice  and  enlargement  of  the  left  lobe 
of  the  liver.  The  tumor  mass  proved  to  be,  as  was  sup- 
posed, at  the  pylorus,  though  in  a  somewhat  unusual  situa- 
tion— entirely,  at  the  time  of  my  visit,  to  the  left  of  the 
middle  line. 

Case  VII.  Dilated  Stomach ;  Tumor  at  the  Pyloric  Orifice. — 
October  1st.  I  saw  to-day,  with  Dr.  W.  B.  Perry,  Mrs.  R.,  aged 
about  sixty  years,  complaining  of  dyspepsia  and  vomiting.  She 
had  been  a  healthy  woman  until  about  a  year  ago,  when  she  began 
to  have  attacks  of  dyspepsia  and  occasionally  of  vomiting.  These 
symptoms  have  become  progressively  aggravated  and  she  has 
within  the  past  three  months  lost  flesh  rapidly.  A  marked  feature 
in  the  case  has  been  the  vomiting  at  intervals  of  very  large  quanti- 
ties of  a  brownish  liquid  mixed  with  portions  of  food. 

Patient  is  a  small-framed  woman,  much  emaciated,  and  looks 
very  feeble.    The  abdomen  is  greatly  distended,  chiefly  on  the  left 


TUMORS  OF   THE   STOMACH. 


17 


side  and  below  the  level  of  tlie  navel.  The  nature  of  the  trouble 
is  at  once  apparent  by  the  active  waves  of  peristalsis  which,  as 
they  pass  from  left  to  right,  bring  out  with  unusual  distinctness  the 
contour  of  the  greater  and  lesser  curvatures,  the  former  passing 
at  a  level  of  about  three  inches 
above  the  pubes,  and  the  latter  mid- 
way between  the  navel  and  ensiform 
cartilage.  The  organ  becomes  un- 
usually hard  and  firm.  Far  over  to 
the  right,  just  at  the  border  of  the 
epigastric  and  umbilical  regions,  there 
is  to  be  plainly  felt  an  irregular, 
nodular  mass,  which  is  movable  and 
is  depressed  on  inspiration.  No  gas 
is  felt  passing  through  it,  but  the  po- 
sition and  characters  suggest  a  pylo- 
ric cancer.  Lavage  had  been  already 
practiced  for  some  time,  but  she  was 
in  too  feeble  a  condition  to  expect 
much  from  any  treatment. 

Dr.  Perry  writes  that  the  patient 
died  on  October  4th. 

Case  VIII.    Dilatation    of    the 
Stomach,  forming  a  Visible  Tumor ;  Nodular  Mass  at  the  Pylo- 
rus.— January  10,  1893,  Captain  ,  of  Virginia,  patient  of  Dr. 

R.  J.  Hicks  and  Dr.  Salzer,  came  complaining  of  dyspepsia  and 
discomfort  after  eating. 

The  patient  has  been  a  healthy  man,  a  free  liver,  and  a  late 
sitter  ;  irregular  in  his  meals.  He  has  not  been  a  chronic  dys- 
peptic, and  has  only  had  an  occasional  attack  of  indigestion  until 
the  onset  of  the  present  trouble.  From  Christmas,  1891,  he  has 
been  ailing,  though  able  to  attend  to  his  business.  He  has  had 
loss  of  appetite  ;  no  special  nausea,  and  has  never  vomited  any 
large  quantity.  After  eating,  however,  particularly  an  ordinary 
meal,  he  has  feelings  of  uneasiness  and  distress,  and  rumbling  and 
distention  in  the  upper  part  of  the  abdomen.  He  has  never  had 
any  severe  pain,  but  a  sense  of  uneasiness  when  the  stomach  is  full 
and  occasionally  a  griping  pain.    Ever  since  the  attack  of  diarrhcea 


Fig.  7.— The  position  of  the  nodule 
and  outline  of  the  stomach  in 
Case  VII. 


18  THE  DIAGNOSIS  OP  ABDOMINAL  TUMORS. 

following  the  influenza  he  has  had  obstinate  constipation.  There 
has  been  persistent  loss  of  weight,  from  a  hundred  and  ninety  to  a 
hundred  and  forty -five  pounds.  Though  attending  to  his  business, 
he  is  at  times  very  weak  and  feeble,  and  feels  that  he  has  lost  a 
great  part  of  his  former  vigor. 

Present  Condition. — Thin,  not  extremely  emaciated,  not  ca- 
chectic ;  color  of  mucous  membrane  good.  Abdomen  a  little  below 
level  of  costal  margin ;  marked  fullness  in  epigastric  and  umbilical 
regions,  leaving  a  definite  furrow  along  right  costal  margin.  Dur- 
ing observation  distention  becomes  much  more  marked,  and  at 
intervals  the  outline  of  the  stomach  is  unusually  distinct.  Waves 
of  peristalsis  pass  actively  from  left  to  right,  and  the  lower  limit  of 
the  stomach  is  seen  to  be  at  least  a  finger's  breadth  below  the  navel. 
To  the  right  it  extends  almost  to  the  costal  margin  opposite  the 
tenth  rib.  The  peristalsis  is  unusually  active,  waves  passing  every 
few  moments,  and  during  their  passage  the  stomach  walls  become 
hard.     Gas  can  be  heard  bubbling  through  the  pylorus. 

Palpation.  — Everywhere  soft ;  no  special  resistance  except  over 
the  stomach  itself  when  in  contraction.  The  pylorus  can  be  felt  in 
the  parasternal  line  at  a  point  midway  between  the  navel  and  the 
tip  of  the  tenth  costal  cartilage.  Here  is  a  firm  thickening  about 
the  size  of  a  large  walnut.  Though  this  is  a  little  far  out  and  low 
for  the  situation  of  the  pylorus,  yet  the  stomach  is  a  good  deal 
depressed  and  the  whole  pyloric  pouch  lies  to  the  left  of  the  middle 
line.  There  is  nothing  special  to  be  felt  along  the  line  of  the  lesser 
curvature.  There  is  a  little  resistance  between  the  costal  margin 
and  the  navel,  which  is  probably  due  to  the  right  lobe  of  the  liver. 
Gas  is  not  felt  to  bubble  through  this  pyloric  mass,  nor  does  it 
seem  to  vary  in  resistance  and  hardness. 

January  ^^d.— Patient  came  into  the  private  ward  under  my 
care,  chiefiy  to  determine  whether  an  operation,  which  had  been 
suggested  by  Dr.  Salzer,  was  advisable  or  not.  On  admission,  the 
stomach  was  very  much  in  the  condition  mentioned  in  the  previous 
note.  Ewald's  test  breakfast,  withdrawn  an  hour  after,  yielded  two 
hundred  and  fifty  cubic  centimetres  of  a  clear,  slightly  yellow  fluid 
containing  partially  digested  bread.  The  odor  was  sour;  the  tests 
for  free  hydrochloric  acid  were  negative. 

He  had  at  times  a  great  deal  of  distress,  owing  to  the  active 


TUMORS  OF  THE  STOMACH.  19 

character  of  the  peristaltic  movements.  He  was  placed  on  a  diet 
of  milk,  beef  juice,  and  egg  albumin,  small  quantities  being  given 
every  two  hours.  The  stomach  was  thoroughly  emptied  night  and 
morning. 

Within  a  few  days  this  treatment  made  the  greatest  change  in 
the  condition  of  dilatation ;  the  organ  reduced  greatly  in  size,  the 
waves  of  dilatation  were  no  longer  evident,  and  he  felt  much  more 
comfortable.  The  reduction  in  the  dilatation  made  a  very  marked 
change  in  the  tumor  mass  above  mentioned.  Instead  of  a  small, 
nodular  body  to  be  felt  far  over  to  the  right,  there  was  now  evident 
to  the  right  of  the  parasternal  line,  in  the  epigastric  region,  a  large, 
solid  mass  of  the  size  of  an  egg.  In  spite  of  the  improvement  in 
the  local  condition,  his  general  strength  failed  with  rapidity,  and 
on  the  28th  it  was  thought  advisable  for  him  to  be  removed  to  his 
home,  where  he  died  early  in  March. 

Case  IX.  Nodular  Tumor  Mass  in  the  Region  of  the  Pylo- 
rus ;  Dilatation  of  the  Stomach. — Eachel  C,  aged  sixty -two 
years,  admitted  February  13th,  complaining  of  a  lump  in  the 
right  side  of  the  abdomen.  Mother  died  of  pulmonary  tuber- 
culosis. 

With  the  exception  of  pulmonary  haemorrhages,  of  which  she 
has  had  in  all  nine  attacks  since  her  nineteenth  year,  and  an  attack 
of  transient  left-sided  hemiplegia  of  five  days'  duration,  she  has 
been  a  healthy  woman.  Has  had  ten  children.  No  special  history 
of  dyspepsia. 

On  September  loth  she  had  for  the  first  time  severe  pain  in  the 
upper  part  of  the  abdomen,  which  continued  for  nine  days,  and  was 
intense  enough  to  keep  her  from  sleep.  Soon  after  this  she  felt  a 
lump  in  the  right  side,  which  has  all  along  been  painful  and  asso- 
ciated with  a  dragging  feeling  when  she  lies  on  the  left  side.  At 
intervals  she  has  a  pufi'ed,  distended  feeling  in  the  abdomen  with 
diffuse  soreness.  Her  appetite  has  been  poor,  and  she  has  had  nau- 
sea sometimes  after  eating,  and  has  several  times  at  night  had 
attacks  of  vomiting.  She  has  bad  no  swelling  of  the  legs.  The 
urine  is  clear ;  no  special  diminution  in  amount.  Patient  is  ema- 
ciated, sallow;  tongue  coated,  white;  pulse  is  88,  regular,  tension  a 
little  increased.  There  is  a  soft  systolic  murmur  at  the  apex ;  with 
the  exception  of  hyper-resonance  in  the  front  and  sides,  and  exag- 


N 


20  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

geration  and  prolongation  of  the  expiratory  murmur,  there  are  no 
changes  to  be  noted  in  the  lungs. 

Abdomen. — There  is  a  slight  prominence  in  the  right  hypo- 
chondrium,  and  on  inspiration  a  tumor  mass  can  be  seen  to  descend 
in  the  parasternal  line.  On  palpation  in  this  region,  just  below  the 
costal  margin,  there  is  a  hard,  rounded  mass,  the  outline  of  which 
can  be  pretty  clearly  made  out  toward  the  median  line,  but  toward 
the  right  it  is  appai'ently  continuous  with  the  margin  of  the  liver. 
It  is  superficial,  nodular,  hard,  and  very  painful.  On  deep  inspira- 
tion, it  descends  almost  to  the  level  of  the  navel,  and  the  fingers 
can  be  then  placed  between  the  tumor  and  the  liver  margin,  and  it 
can  be  held  down.  Gas  can  be  felt  bubbling  through  the  mass. 
On  percussion,  there  is  a  flat  tympany.  When  quiet  and  in  repose 
no  peristalsis  can  be  seen  as  a  rule.  When  the  patient  turns  over 
on  the  left  side  the  mass  falls  forward  and  to  the  left,  and  can 
readily  be  grasped  between  the  hands.  The  epigastric  region  is  a 
little  flattened ;  sometimes  distinctly  depressed.  The  lower  umbili- 
cal region,  on  the  contrary,  is  fidl. 

On  dilatation  with  tartaric  acid  and  bicarbonate  of  sodium,  the 
stomach  is  seen  to  be  depressed  and  dilated.  The  lesser  curvature 
passed  just  at  the  level  of  the  navel ;  the  greater  curvature  at  a  dis- 
tance of  seven  centimetres  below.  Waves  of  peristalsis  were  then 
seen  in  the  stomach  walls  passing  from  left  to  right,  and  sometimes 
the  organ  showed  an  hou7'-glass  contraction. 

The  test  breakfast  showed  the  presence  of  the  organic  acids,  ab- 
sence of  free  hydrochloric.  Material  washed  out  was  dark  in  color 
and  smell ed  very  sour. 

The  liver  is  not  enlarged ;  the  spleen  not  palpable ;  no  enlarge- 
ment of  the  external  glands. 

Case  X.  Enormous  Dilatation  of  the  Stomach,  forming  a 
Visible  Tumor;  Ridge-like  Thickening  in  the  Pyloric  Region. — 
Emma  H.,  aged  thirty  years,  colored,  admitted  (to  the  gynaecolog- 
ical ward  and  transferred)  April  28,  1893,  complaining  of  swelling 
of  the  abdomen,  nausea,  and  vomiting.  Nothing  of  any  moment  in 
the  family  history.  She  was  healthy  until  about  eight  months  ago, 
when  she  began  to  have  dyspepsia  and  distress  after  eating.  She 
has  not  infreqviently  had  attacks  of  vomiting.  Lately  she  has  been 
much  nauseated  after  eating,  and  has  had  pain  and  swelling  of  the 


TUMORS  OF  THE   STOMACH. 


21 


abdomen,  with  much  belching.  Six  months  ago  she  brought  up 
food  mixed  with  blood.  Lately  she  has  only  been  vomiting  food. 
She  has  lost  in  weight  within  the  past  year,  and  has  noticed  that 
she  passes  much  less  urine  than  formerly.  The  patient  is  moder- 
ately wasted;  weight,  a  hundred  and  five  pounds;  lips  and  mucous 
membranes  of  good  color.  Temperature  normal ;  pulse,  112.  The 
abdomen  is  flaccid,  but  a  little  prominent,  and,  on  inspection,  very 
marked  waves  of  peristalsis  are  seen  passing  from  left  to  right. 
They  occupy  a  considerable  area,  extending  from  just  below  the 
costal  margin  to  midway  between  the  navel  and  the  pubes.  As 
they  pass,  the  skin  is  lifted  in  very  definite  prominences.  On  palpa- 
tion, there  is  very  marked  succussion,  and,  on  changing  from  side 
to  side,  the  dullness  alters  as  the  fluid  sags  with  the  change  of  posi- 
tion. On  inflating  the  stomach,  it  is 
found  to  occupy  nearly  the  whole  ab- 
domen. The  tympany  begins  above 
at  the  fifth  rib  and  extends  to  the 
pubes.  The  lesser  curvature  is  seen 
just  above  the  umbilicus.  There  is 
very  prominent  distention  in  the 
pyloric  region,  and  the  gastric  tym- 
pany extends  nearly  to  the  right  an- 
terior superior  spine.  No  nodular 
masses  or  tumor  could  be  felt.  With 
the  stomach  tube  a  large  quantity  of 
a  greenish-yellow  liquid  with  rem- 
nants of  food  was  removed.  When 
the  stomach  was  emptied  there  then 
could  be  felt  midway  between  the 
umbilicus  and  the  costal  margin  a 
ridge-like  mass  about  the  size  of  the 
thumb,    which    was    freely    movable 

and  descended  with  inspiration,  and  which  subsequent  exami- 
nations showed  was  extremely  variable,  not  being  palpable  when 
the  organ  was  very  greatly  distended.  With  lavage  and  feeding  at 
short  intervals  the  patient  improved  very  much  and  the  stomach 
reduced  very  materially  in  size  and  she  gained  in  weight. 

From  the  prolonged  history  of  dyspepsia  and  the  fact  that  she 


Fig.  8.— Outline  of  the  stomach  in 
Case  X,  showing  the  position 
of  the  ridge-like  mass. 


22 


THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 


had  on  several  occasions  vomited  blood,  this  was  very  probably  an 
instance  of  dilatation  from  the  cicatrization  of  an  ulcer  ;  and  the 
small,  elongated  nodular  thickening  in  the  region  of  the  pylorus 
also  suggested  this  condition. 

General  Remarks  on  the  Diagnosis  of  the  Tumor  caused 
hy  Dilated  Stomach. — Inspection  gives  most  important  in- 
formation, the  value  of  which  may  be  gathered  from  the 
fact  that  in  these  ten  cases  the  diagnosis  was  made  de  visu. 
Bear  in  mind,  in  the  first  place,  that  a  dilated  stomach  may 
occupy  every  region  of  the  abdomen  except  the  upper  part 
of  the  epigastric  and  may  form  a  very  prominent  tumor. 


Fig.  9.— Profile  view  of  the  abdomen  of  Sarah  A.,  aged  sixty-five,  showing  the  tumor 
formed  by  the  dilated  stomach.    From  a  photograph  taken  during  life. 

The  photographs  (Figs.  9  and  10)  which  I  show  you  illus- 
trate this  very  well.  They  were  taken  during  life  from  a 
woman,  aged  sixty-five  years,  who  was  admitted  to  the 
hospital  complaining  of  attacks  of  vomiting  which  had 
persisted  for  nearly  two  years,  during  which  time  she  had 
become  gradually  emaciated  and  very  weak.  She  had  at 
intervals  brought  up  enormous  quantities  of  fluid.  Ou  in- 
spection, the  abdomen  was  greatly  distended,  particularly 
on  the  left  side  and  in  the  umbilical  and  hypochondriac 


TUMORS  OF  THE  STOMACH. 


23 


regions.  It  was  uniform,  but  at  intervals  there  were  slight 
irregularities  and  elevations ;  no  marked  waves  of  contrac- 
tion. On  palpation,  the  abdomen  was  everywhere  soft,  ex- 
cept at  a  point  to  the  right  of  and  just  below  the  navel, 
where  there  was  a  hard,  resistant  mass.  At  first  it  seemed 
scarcely  possible  that  the  entire  abdominal  distention  could 
be  due  to  a  dilated  stomach,  but  the  reduction  in  size  after 


Fio.  10.— Tumor  of  the  abdomen  caused  by  a  dilated  stomach ;  case  of  Sarah  A. 
From  a  photograph  taken  during  life. 

vomiting  and  after  lavage,  the  depth  to  which  the  stomach 
tube  could  pass,  and  the  irregular  waves  of  protrusion  left 
no  doubt  that  the  distention  was  due  to  an  enormously  di- 
lated stomach.  She  died  November  16,  1889.  The  photo- 
graphs (Figs.  9  and  10)  show  the  profile  and  front  views 
taken  during  life,  and  Fig.  11,  from  a  photograph  taken  after 
death,  shows  the  position  of  the  organ  and  its  enormous 
enlargement.  There  was  cancerous  stricture  of  the  pylorus. 
The  most  prominent  distention  is  usually  in  the  left 


24 


THE  DIAGNOSIS  OP  ABDOMINAL  TUMORS. 


half  of  the  umbilical  region,  but  it  may  be  chiefly  below 
the  navel.  A  definite  stomach  contour  may  bo  seen  very 
plainly  in  many  instances  of  dilatation  from  stenosis  of 
the  pylorus.     At  intervals,  during  the  contraction  of  the 


Fig  11.— Showing  the  position  and  size  of  the  stomach  in  Sarah  A. 
From  a  photograph  taken  at  the  autopsy. 

stomach  walls,  the  outline  of  the  greater  curvature  de- 
scends on  the  left  side,  curving  at  a  level  of  the  anterior 
superior  spine,  and  passing  to  the  right  at  a  variable  dis- 
tance above  the  pubes,  sometimes  not  more  than  three  or 
four  centimetres,  sometimes  midway  between  the  pubes 


TUMORS  OF  THE  STOMACH,  25 

and  the  naval.  Curving  upward,  it  ends  either  in  the  left 
lumbar  or  more  frequently  in  the  right  upper  quadrant  of 
the  umbilical  region,  sometimes  appearing  to  pass  beneath 
the  right  costal  margin.  The  lesser  curve  is  frequently- 
much  more  distinct,  the  line  passing  vertically  parallel 
with  the  left  border  of  the  sternum  or  in  the  parasternal 
line,  curving  to  the  left  of  the  navel,  and  often  during  the 
contraction  of  the  organ  forming  a  very  well  marked, 
sharply  defined  contour  at  or  a  little  below  the  level  of  the 
navel.  I  have  found  the  greatest  surprise  expressed  by 
practitioners  that  the  stomach  should  be  so  low,  that  even 
the  lesser  curvature  should  be  below  the  level  of  the 
navel ;  but  this  is  frequently  the  case  in  extreme  dilata- 
tion. In  the  first  place,  then,  the  outline  of  the  organ  may 
give  to  you  at  a  glance  the  diagnosis.  Secondly,  inspec- 
tion is  of  the  greatest  value  in  determining  the  presence 
of  peristalsis.  Though  enormously  stretched,  there  is  hy- 
pertrophy of  the  muscular  coats  and  great  increase  in  the 
activity  and  frequency  of  the  movements.  In  all  of  the 
cases  they  were  present.  The  movements  are  of  two 
kinds,  which  may  be  seen  together  or  separately :  First, 
peristaltic  waves,  passing  slowly  from  left  to  right,  more 
rarely  antiperistalsis,  from  right  to  left.  The  mere  ex- 
posure of  the  abdomen  to  the  cool  air  is  usually  suffi- 
cient to  excite  them.  Sometimes  the  stimulus  of  palpa- 
tion is  required,  or  the  flapping  of  the  skin  with  a  wet 
towel.  During  the  passage  of  these  waves  the  outline  of 
the  organ  becomes  evident ;  sometimes,  as  already  noted, 
the  greater  and  lesser  curvatures  are  plainly  to  be  seen. 
Sometimes,  too,  as  the  waves  reach  the  pyloric  region  a 
tumor  mass  may  be  rendered  visible  or  made  more  promi- 
nent. The  stomach  may  be  so  enormously  dilated  that  the 
walls  are  in  a  condition  of  paralytic  distention  and  no  peri- 
staltic waves  are  seen,  as  in  the  case  from  which  Figs.  9 
to  11  were  taken. 


26  THE  DIAGNOSIS  OP  ABDOMINAL  TUMORS. 

A  second  variety  of  movement  to  be  seen  in  a  dilated 
stomach  consists  in  a  slowly  performed  irregular  protru- 
sion here  and  there  of  the  stomach  wall,  which  lifts  the 
skin  of  the  abdomen  in  a  hemispherical  boss  or  prominence. 
This  may  develop  at  any  point,  more  frequently  toward  the 
greater  curvature.  They  usually  occur  with  the  peristaltic 
waves  and  in  combination  may  throw  out  in  bold  relief  the 
contour  of  the  organ,  sometimes  also  giving  to  it  a  some- 
what hour-glass  shape,  owing  to  corresponding  depressions 
about  the  middle  of  the  greater  and  of  the  lesser  curva- 
tures. The  upper  depression  is  seen  in  Fig.  1.  These 
irregular  protrusions  may  be  seen  in  enormously  dilated 
stomachs,  in  which  the  peristaltic  waves  are  no  longer 
visible,  as  in  the  case  just  mentioned,  of  which  I  have 
shown  you  the  photographs.  Let  me  again  emphasize  the 
value  of  inspection  by  reminding  you  that  of  the  thirteen 
instances,  in  ten  the  diagnosis  was  manifest  on  inspection 
alone. 

Palpation. — Four  points  may  be  determined  by  this 
procedure.  The  existence  of  the  splashing  sound  or  suc- 
cussion,  the  clapotage,  which  is  always  present,  and  which, 
though  in  no  way  diagnostic,  yet  is  of  value  in  connection 
with  a  prominence  in  the  left  flank  and  lower  umbilical 
region.  It  is  of  use  also  in  determining  the  lowest  level  of 
the  organ.  With  the  hand  on  the  abdomen,  as  the  peri- 
staltic waves  pass,  or  as  the  irregular  protrusions  develop, 
you  will  notice  that  the  organ  hardens ;  and  toward  the 
pylorus,  as  the  wave  is  followed,  there  may  be  an  exceed- 
ingly firm  contraction.  After  persisting  for  a  minute  or  so 
the  muscular  walls  relax  and  are  again  soft  and  readily  de- 
pressed. In  some  instances  the  muscular  contraction  at 
the  pylorus  is  extremely  firm  and  hard,  and  the  relaxation 
beneath  the  hand  reminds  one  of  that  of  the  uterus.  A 
third  point  of  importance,  particularly  in  palpation  of  the 
pyloric  region,  is  the  gurgling  of  gas  through  the  pyloric 


TUMORS  OF  THE  STOMACH.  27 

orifice.  This  is  usually  very  marked  when  tlie  stomach,  is 
inflated,  but  it  may  occur  spontaneously  and  in  some  in- 
stances at  regular  intervals.  In  doubtful  tumors  of  this 
region  this  is  a  sign  to  which  scarcely  sufficient  attention 
has  been  paid.  Its  importance  will  be  referred  to  again  in 
connection  with  tumors  of  the  intestines,  as  in  one  case  in 
the  series  it  saved  us  from  a  somewhat  serious  error.  And 
lastly  it  is  by  palpation  chiefly  that  we  are  enabled  to  de- 
termine the  presence  or  absence  of  a  pyloric  tumor.  And 
here  you  have  to  bear  in  mind  that  in  dilatation  of  the 
stomach  the  pyloric  tumor  may  be  extremely  variable, 
readily  felt  to-day,  scarcely  palpable  to-morrow,  dependent 
very  much  upon  the  grade  of  distention.  You  will  find 
this  very  strikingly  illustrated  after  washing  out  the  stom- 
ach, when  perhaps  a  comparatively  small  pyloric  mass  may 
be  found  to  be  quite  large  and  prominent.  When  the 
organ  is  extremely  dilated,  the  tumor  may  be  scarcely  pal- 
pable. This  was  particularly  well  illustrated  in  Case  VII, 
which  was  sent  to  me  by  Dr.  Salzer  for  an  opinion  as  to 
the  advisability  of  a  Loretta's  operation.  The  tumor  at  the 
pylorus,  which  at  the  first  examination  seemed  not  larger 
than  a  walnut,  after  thoroughly  emptying  the  stomach  was 
found  to  be  a  solid  mass  the  size  of  an  egg. 

Percussion  combined  with  palpation  brings  out  most 
clearly  the  splashing  sound,  which  in  cases  of  extreme  dila- 
tation may  be  most  evident  below  the  transverse  navel 
line.  The  extent  of  stomach  tympany  will  vary  with  the 
position  of  the  patient.  In  the  recumbent  posture  it  may 
extend  in  the  nipple  line  from  the  fifth  costal  cartilage  to 
within  two  or  three  fingers'  breadth  of  the  pubes.  In  the 
erect  posture  a  line  of  transverse  dullness  may  be  accu- 
rately defined,  which  will  sink  as  the  patient  is  gradually 
placed  in  the  recumbent  position.  The  extent  of  stomach 
tympany  varies,  of  course,  with  the  amount  of  fluid  con- 
tents, and  after  the  attacks  of  vomiting  in  which  large 


28  THE  DIAGNOSIS  OP   ABDOMINAL  TUMORS. 

quantities  of  liquid  are  brouglit  up  it  may  "be  very  much, 
extended. 

In  doubtful  cases  inflation  of  the  organ  is  a  most  valua- 
ble method,  and  is  best  accomplished  by  the  use  of  the  bi- 
carbonate of  sodium  and  tartaric  acid,  from  half  a  tea- 
spoonful  to  a  teaspoonful  dissolved  separately  and  taken 
one  after  the  other,  the  patient  being  directed  to  refrain, 
as  far  as  possible,  from  belching.  Inspection  may,  through 
thin  abdominal  walls,  at  once  reveal  the  distended  stomach, 
displaying  active  peristaltic  movements.  The  percussion 
limits  can  then  be  also  more  definitely  defined.  Palpation 
in  the  pyloric  region  may  give  the  sensation  of  gas  bub- 
bling through  into  the  duodenum.  This  method  of  in- 
flation is  more  satisfactory  on  the  whole  than  that  of 
pumping  air  into  the  stomach.  When  gastric  ulcer  is  sus- 
pected these  proceedings  should  be  practiced  with  great 
caution  or  omitted  altogether. 

Auscultation  gives  little  information  of  value.  One 
hears  the  sizzling  sound  of  the  gas  as  the  contents  of  the 
stomach  are  churned  about ;  sometimes  quite  loud  gurgling 
is  heard  as  the  fluid  passes  through  the  pylorus,  often  loud 
enough  to  be  heard  at  a  distance.  The  succession  splash 
may  be  obtained  by  placing  the  ear  upon  the  abdomen, 
and  either  shaking  the  patient  or  asking  him  to  depress 
suddenly  the  diaphragm. 

The  characters  of  the  contents  of  the  dilated  stomach, 
the  general  symptoms,  and  special  features  I  shall  not  dis- 
cuss, as  the  subject  before  us  is  more  particularly  the  form 
of  abdominal  tumor  caused  by  it.  To  one  special  point, 
however,  I  may  refer,  as  it  is  of  some  moment  in  the  treat- 
ment of  these  cases  of  dilatation  from  stenosis  of  the  pylo- 
rus. The  recent  experiments  of  von  Mering  show  that 
water  is  not  absorbed  to  any  extent  from  the  stomach, 
but  is  passed  into  the  intestine,  usually  at  regular  inter- 
vals, by  a  rhythmical  opening  and  closing  of  the  pylorus. 


TUMORS  OF  THE  STOMACH.  29 

Not  only  is  the  resorption  of  water  extremely  slight,  but 
hand  in  hand  with  the  absorption  of  the  sugars  and  pep- 
tones there  is  actually  a  secretion  of  water  corresponding 
in  some  measure  to  the  amount  of  substances  absorbed. 
With  these  facts  correspond  closely  certain  points  in  the 
history  of  dilatation  of  the  stomach.  The  organ  is  never 
empty,  and  even  after  it  is  pumped  out  as  much  as  pos- 
sible, fluid  will  reaccumulate  without  any  liquid  having 
been  taken  ;  and  frequently  patients  will  remark  in  aston- 
ishment that  the  amount  which  they  have  vomited  far  ex- 
ceeds in  quantity  what  has  been  taken  by  the  mouth.  This 
explains  also  other  striking  symptoms  in  excessive  dilata- 
tion of  the  stomach — namely,  the  great  reduction  in  the 
amount  of  urine  secreted,  the  dryness  of  the  skin,  and  the 
wasting,  which  is  proportionate  to  the  degree  and  persist- 
ency of  the  dilatation  rather  than  to  the  nature  of  the  ob- 
struction. Unverricht  has  suggested  to  supplement  this 
water  depletion  by  the  use  of  large  enemata,  two  litres 
daily  of  salt  solation,  the  use  of  which  he  states  has  been 
followed  by  marked  improvement  in  the  symptoms,  and  in 
some  instances  by  an  increase  in  weight. 

And,  lastly,  there  is  the  question.  What  conditions  may 
be  confounded  with  dilatation  of  the  stomach  ?  Nothing, 
in  reality,  if  the  examination  is  made  systematically  and 
thoroughly.  The  physical  signs  alone  are  generally  suffi- 
cient, and,  when  taken  in  connection  with  the  general 
symptoms,  quite  distinctive  ;  thus  there  was  not  one  of  the 
cases  in  this  series  about  which  a  shade  of  doubt  existed. 
Yet  mistakes  have  arisen,  some  of  a  remarkable  nature, 
owing  to  ignorance  of  the  fact  that  the  dilated  organ  may 
be  chiefly  to  the  left  of  and  below  the  umbilicus.  The 
tumor  has  been  mistaken  for  an  ovarian  cyst  (Detroit 
Lancet,  January,  1880),  and  even  after  tapping  and  the 
withdrawal  of  a  dark-colored  fluid  containing  grains  of 
rice,  pieces  of  potato,  bread,  meat,  etc.,  laparotomy  was 


30  THE  DIAGNOSIS  OP  ABDOMINAL  TUMORS. 

performed  for  ovarian  tumor.  Tlie  enormous  dilatation, 
as  sliown  in  Figs.  9  and  10,  with  paralytic  distention  and 
absence  of  the  peristaltic  waves,  might,  and  indeed  did, 
when  the  stomach  was  very  full,  simulate  ascites,  but  no 
serious  difficulty  could  arise  in  the  differentiation.  Tumors 
of  the  colon,  causing  obstruction,  lead  to  great  distention 
of  the  large  bowel,  in  which  active  waves  of  peristalsis 
may  be  seen  passing  from  right  to  left.  Usually  the  abdo- 
men is  distended  more  uniformly  or  chiefly  in  the  epigas- 
tric zone,  and  intestinal,  not  gastric,  symptoms  have  been 
present,  and  the  inflation  of  the  stomach  alone,  or,  if  prac- 
ticable, combined  inflation  of  the  stomach  and  colon,  will 
usually  give  information  upon  which  you  may  base  a 
definite  conclusion. 

A  dilated  stomach,  causing  a  prominent  tumor  of  the 
abdomen,  is  almost  invariably  due  to  stenosis  of  the  pylo- 
rus. As  already  mentioned,  in  all  of  the  cases  a  tumor 
was  evident,  and  in  all  the  condition  was  that  to  which  the 
term  dilatation  of  the  stomach  is  more  correctly  limited.  In 
rare  instances  a  prominent  tumor  may  be  caused  by  mus- 
cular insufficiency,  as  it  is  called,  or  atony  of  the  stomach, 
and  occasionally,  by  change  in  the  position  of  the  organ, 
the  so-called  descensus  ventriculi.  The  differential  diag- 
nosis of  these  conditions  you  will  find  fully  given  in  the 
special  works  above  mentioned.  I  may,  however,  remark 
that  only  in  very  exceptional  instances  of  atony  of  the 
stomach  or  of  descensus  ventriculi  are  the  peristaltic 
waves  seen.  In  women  who  have  borne  many  children, 
and  who  have  the  extremely  relaxed  abdominal  walls,  the 
condition  which  GMnard  has  termed  enteroptosis  may  be 
associated  with  great  depression  and  enlargement  of  the 
stomach.  In  some  cases  the  decision  is  very  difficult.  I 
show  you  here  the  stomach  outlines  of  a  patient  who 
at  first  we  thought  had  dilatation  of  the  stomach  from 
pyloric  obstruction.      The  organ  reached  nearly  to   the 


TUMORS  OP   THE  STOMACH.  3]^ 

pubes  ;  the  lower  curvature  was,  however,  at  the  um- 
bilicus. The  vertical  measurements  of  the  stomach 
were  twenty  centimetres  in  the  middle  line,  thirty-one 
centimetres  from  the  lower  border  of  the  eighth  costal 
cartilage  to  the  middle  of  Poupart's  ligament,  and  the 
transverse  diameter  twenty-eight  centimetres  and  a  half. 
Occasionally  there  were  to  be  seen  peristaltic  waves  cross- 
ing from  left  to  right.  No  tumor  was  at  any  time  to  be 
felt.  The  liver  was  depressed  ;  the  kidneys  were  movable. 
The  examination  for  free  hydrochloric  acid  was  variable ; 
sometimes  it  was  present,  sometimes  absent.  She  had  had 
dyspepsia  for  some  years,  and  within  the  year  much  belch- 
ing and  some  vomiting,  but  never  of  very  large  quantities 
of  liquid.  With  lavage  and  careful  dieting  she  improved 
very  much,  and  gained  fourteen  pounds  in  three  months. 
We  subsequently  lost  sight  of  her. 

II.  Tumor  formed  by  Contracted  Stomach. — There 
are  two  conditions  in  which  the  stomach  itself,  in  a  state  of 
contraction,  may  form  a  definite,  palpable  tumor — first,  in 
occlusion  of  the  oesophagus,  when  the  organ  shrinks  and 
may  be  sometimes  felt  as  a  narrow,  firm  cord,  lying  below 
the  margin  of  the  left  lobe  of  the  liver ;  and,  second,  when 
there  is  diffuse  thickening  of  the  stomach  walls  with  con- 
traction of  the  lumen  in  cirrhosis  or  in  diffuse  cancerous 
infiltration.  The  following  is  a  remarkable  instance  of  the 
latter  condition,  which  presented  a  well-marked  tumor : 

Case  XI.  Tumor  in  the  Epigastric  Region,  consisting  of  the 
Stomach  diffusely  Infiltrated  icith  Carcinoma.— George  H.,  aged 
sixty  years,  tailor  by  occupation,  German,  admitted  on  April  4, 
1893,  complaining  of  indigestion. 

Has  always  been  strong  and  well  ;  had  gonorrhoea  when 
twenty ;  has  been  a  moderate  drinker ;  does  not  use  tobacco. 

Present  illness  began  about  five  months  ago  with  uncomfort- 
able feelings  in  the  epigastrium  and  constipation.  Prior  to  this  he 
states  that  he  had  no  dyspepsia.      Soon  he  began  to  have  much 


32 


THE  DIAGNOSIS  OP  ABDOMINAL  TUMORS. 


distention  after  meals,  and  water  brash.  He  has  never  had  any- 
vomiting,  but  he  spits  up  a  great  deal  of  mucus.  There  is  some- 
times a  sharp  pain  in  the  abdomen,  but,  as  a  rule,  there  is  only  a 
heavy,  uneasy  sensation  after  eating.  In  January  he  noticed  that 
there  was  a  swelling  above  the  left  clavicle.  In  March  he  had 
one  or  two  attacks  of  vomiting,  and  he  has  been  much  troubled 
with  hiccough. 

He  applied  at  the  dispensary  about  the  end  of  January,  and  a 
stomach  tube  was  introduced,  but  it  brought  up  a  little  blood. 
Since  his  Dlness  began  he  has  lost  forty-five  pounds  in  weight. 

Present  Condition. — Considerable  emaciation ;  lips  and  mucous 
membranes  of  good  color.      Above  the  left  clavicle  the  lymph 

glands  are  enlarged  and  hard ;  slight- 
ly enlarged  above  the  right.  They  are 
also  somewhat  enlarged  in  the  in- 
guinal region.  The  thoracic  organs 
are  normal. 

The  abdomen  is  flaccid,  symmet- 
rical ;  a  little  full,  perhaps,  in  the 
epigastric  region.  On  palpation,  a 
ridge-like  mass  is  to  be  felt  in  the 
left  hypochondrium,  which  extends 
across  the  middle  line  to  the  right 
side  as  far  as  the  parasternal  line.  It 
descends  with  deep  inspiration  as  low 
as  the  umbilicus.  The  lower  edge  is 
very  distinct  and  feels  somewhat  like 
a  rolled  omentum.     It  can  scarcely 

Fig.  12.— Showing  the   po.sition  of  ,    i     i  r  j.t,     t  ^i 

the  tumor  mass  consisting  of  dif-    ^^  Separated  above  from  the  liver,  the 
fuseiy  infiltrated  stomach  walls    Q^gQ  of  which  is  just  palpable.    There 

in  Case  XI.  , ,  /-x     . 

is  a  flat  tympany  over  the  mass.  On  m- 
flation  of  the  stomach,  vomiting  occurred  and  a  good  deal  of  distress. 

The  urine  was  negative. 

On  April  21st  the  patient  had  tenderness  along  the  saphenous 
vein  and  the  calf  of  the  leg,  and  there  was  oedema  of  the  ankle  and 
of  the  leg. 

The  patient  left  hospital  on  May  5th,  and  died  two  days  after- 
ward at  his  home,  where  the  autopsy  was  made  by  Dr,  F.  R.  Smith 


TUMORS  OF  THE  STOMACH.  33 

and  Dr.  F.  Fincke,  who  brought  the  specimens  to  the  laboratory. 
There  was  nothing  of  special  note  in  the  thoracic  organs  excej)t 
that  there  was  some  adhesion  of  the  layers  of  the  pericardium. 

The  peritonaeum  was  smooth.  The  stomach,  intestines,  and 
mesentery  were  removed  together.  The  liver  was  not  enlarged, 
was  a  little  granular  on  section,  and  firm.  The  omentum  was 
uninvolved.  The  stomach  was  free  on  its  anterior  wall,  on  the 
greater  part  of  the  posterior  wall,  and  on  the  greater  curvature,  but 
was  closely  adherent  at  the  pyloric  zone  to  the  contiguous  parts. 
The  organ  was  reduced  in  size,  measuring  in  its  extreme  length 
thirteen  centimetres  ;  transverse  diameter,  from  four  to  five  cen- 
timetres. It  was  extremely  firm  and  dense,  and  the  tumor  mass 
which  was  felt  during  life  corresponded  to  it,  and  the  hard,  resist- 
ant edge  corresponded  to  the  greater  curvature.  The  orifices  were 
not  narrowed  ;  the  walls  were  extremely  thickened,  from  eight  to 
ten  millimetres  at  the  cardia,  and  from  thirteen  to  fourteen  at  the 
pylorus.  The  thickening  was  due  partly  to  the  great  hypertrophy 
of  the  muscularis,  but  chiefly  to  the  submucosa,  which  measured 
from  three  to  five  millimetres.  The  mucous  membrane  was  uni- 
formly smooth,  excessively  thin,  and  showed  no  erosions  or  ulcera- 
tions. 

On  microscopical  examination,  the  mucous  membrane  was 
almost  entirely  deficient.  The  submucosa  was  occupied  by  large 
groups  of  cancer  cells  between  strands  of  connective  tissue.  The 
layers  of  the  muscular  coat  were  much  hypertrophied,  and,  invad- 
ing the  interstitial  tissue  and  sometimes  in  the  muscular  bundles 
themselves,  were  numerous  cancerous  cells. 

The  pancreas  was  firm  and  hard  and  uniformly  surrounded  by 
thickened  peritoneal  tissue,  infiltrated  in  places  with  cancerous 
new  growth.  The  substance  of  the  gland  itself  was  normal.  The 
mesentery  was  enormously  thickened,  measuring  close  to  the  root 
three  centimetres.  The  peritonaeum  was  thickened,  presenting  in 
places  flat  areas  of  carcinoma,  and  the  mesenteric  glands  were  uni- 
formly enlarged  and  cancerous. 

While  we  regarded  this  case  as  one  of  cancer  of  the 
stomach,  we  certainly  were  not  aware  of  its  remarkable 
character.    The  tumor  so  readily  felt  was  thought  to  be 


34  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

an  infiltration  of  part  of  the  stomacli  wall,  whereas  in 
reality  it  corresponded  definitely  to  the  organ  itself.  The 
diffuse  infiltrating  carcinoma  has  to  be  carefully  distin- 
guished from  the  true  cirrhosis  of  the  stomach,  consisting 
of  fibrous  overgrowth.  The  distinction  can,  however,  only 
be  made  by  the  microscope,  unless,  of  course,  there  is 
secondary  infection  of  glands  and  neighboring  organs.  In 
this  instance  the  lymph  glands  were  infected,  and  I  would 
call  your  attention  particularly  to  the  fact  that  the  supra- 
clavicular glands  on  the  left  side  were  also  involved — a 
situation  in  which  secondary  tumors  are  sometimes  seen 
in  cancer  of  the  stomach  and  of  the  oesophagus,  and  in 
which  their  presence  may  be  of  the  greatest  value  in  diag- 
nosis. Not  only  may  there  be  a  primary  infiltrating  car- 
cinoma of  the  stomach  not  distinguishable  macroscopic- 
ally  from  cirrhosis  of  the  organ,  but  Dr.  Welch,  in  show- 
ing this  specimen  at  the  Hospital  Medical  Society,  called 
attention  to  an  instance  which  he  had  reported  of  second- 
ary infiltrating  carcinoma  of  the  stomach  in  a  woman, 
aged  forty  years,  who  had  double  carcinoma  of  the  ovaries. 
This  beautiful  plate,  in  Carswell's  Morbid  Anatomy,  illus- 
trates the  condition  very  well. 


LECTURE  II. 

NODULAR  AND   MASSIVE   TUMORS   OF   THE   STOMACH. 

We  considered  in  the  first  lecture  tlie  cases  in  which 
the  tumor  was  formed  by  the  stomach  itself,  either  in  a 
state  of  extreme  dilatation  or  extreme  contraction.  In 
twenty-one  cases  of  the  series  nodular  growths  or  diffuse 
thickening  and  infiltration  were  present ;  in  three  instances 
a  massive  infiltration.  And  first  let  me  remind  you  of  one 
or  two  anatomical  facts.  The  only  fixed  portion  of  the 
stomach  is  the  cardiac  orifice,  which  is  covered  deeply  by 
the  left  lobe  of  the  liver,  and  externally  corresponds  to  the 
seventh  left  costal  cartilage  near  the  sternum.  The  organ 
itself  varies  much  in  position  with  the  degree  of  fullness 
or  emptiness.  The  pylorus  may  be  in  the  middle  line,  but 
when  the  organ  is  distended  it  is  from  six  to  eight  cen- 
timetres to  the  right.  It  is  usually,  not  always,  covered  by 
the  liver.  Fully  two  thirds  of  the  stomach  lie  beneath  the 
ribs  in  the  left  hypochondrium,  and  in  contact  with  the 
abdominal  walls  are  only  part  of  the  body  and  the  pyloric 
region.  Practically,  however,  we  find  that  the  organ  is 
often  depressed  and  so  enlarged  that  a  much  more  ex- 
tended area  than  usually  stated  is  exposed  for  palpation. 
Tumors  limited  to  the  cardiac  orifice  can  not  be  felt  at  all, 
even  when  extensive.  Those  of  the  fundus  and  the  pos- 
terior wall,  and  a  considerable  part  of  the  lesser  curvature, 
can  only  be  felt  when  of  large  size.  Tumors  of  a  consid- 
erable extent  of  the  greater  curvature  and  a  large  section 
of  the  anterior  wall  are  in  accessible  situations.    It  is  of 

35 


36  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

interest  here  to  note  the  situation  of  new  growths  in  the 
stomach,  as  determined  in  thirteen  hundred  cases  analyzed 
by  Professor  Welch.  The  distribution  was  as  follows: 
Pyloric  region,  791;  lesser  curvature,  148;  cardia,  104; 
posterior  wall,  68 ;  the  whole  or  greater  part  of  the  stom- 
ach, 61 ;  multiple  tumors,  45  ;  greater  curvature,  34  ;  ante- 
rior wall,  30 ;  fundus,  19 — so  that  at  least  three  fifths  of  all 
tumors  occupy  the  pyloric  region. 

The  cases  which  have  been  under  observation  may  be 
grouped  into  tumors  at  the  pyloric  region,  tumors  of  the 
body  of  the  stomach,  and  massive  tumors  occupying  a  very 
large  area  of  the  organ. 

(a)  Tumors  of  the  Pyloric  Region.— Of  the  twenty- 
four  cases,  there  were  seventeen  with  a  tumor  mass  of  some 
size  or  form  to  be  felt  at  the  distal  portion  of  the  organ. 
In  ten  of  these  dilatation  of  the  stomach  was  present,  prom- 
inent enough  to  itself  cause  a  tumor  and  have  been  consid- 
ered in  the  first  lecture. 

Before  entering  upon  a  description  of  the  cases  an  im- 
portant question  arises :  Is  the  normal  pylorus  palpable  ? 
It  may  be  answered,  I  think,  in  the  affirmative,  with  cer- 
tain qualifying  conditions.  The  pylorus  forms  a  definite 
ring-like  muscular  valve,  readily  to  be  seen  and  felt  in  the 
exposed  organ.  Whether,  as  has  been  stated,  it  relaxes 
and  contracts  rhythmically  at  definite  intervals  has  not 
been  fully  determined,  but  I  would  remind  you  of  the 
statement  made  by  Beaumont,  in  his  experiments  on  the 
movements  of  the  stomach  of  St.  Martin,  that  when  the 
thermometer  was  placed  toward  the  pyloric  orifice  it  was 
at  first  firmly  grasped,  and  then,  by  gentle  relaxation, 
allowed  to  pass.  If  the  stomach  be  exposed  in  a  cadaver 
and  a  couple  of  towels  laid  upon  it,  on  palpation  over  them 
the  pyloric  ring  is  readily  felt.  So  also,  I  believe,  it  may 
sometimes  be  detected  during  life.  Though  normally  cov- 
ered by  the  anterior  margin  of  the  liver,  it  is  freely  ex- 


NODULAR  AND   MASSIVE  TUMORS  OF  THE  STOMACH.    37 

posed  in  a  very  considerable  number  of  cases,  and  when 
the  stomach  is  depressed  or  in  a  state  of  atony  the  jjyloric 
ring  is  always  below  the  edge  of  the  liver.  In  persons  with 
very  thin  walls,  particularly  in  cases  of  enteroptosis  in 
women,  palpation  in  the  boundary  of  the  epigastric  and 
umbilical  regions  may  discover  a  small,  transversely  placed 
body,  varying  in  position,  with  respiration  which  some- 
times gives  the  impression  of  a  structure  alternately  in 
contraction  and  relaxation.  In  some  cases  it  may  even  be 
rolled  beneath  the  finger.  At  intervals  gas  is  felt  to  bubble 
through  it.  From  the  pancreas,  which  is  also  sometimes 
palpable,  it  is  readily  distinguished  by  the  alternate  relaxa- 
tion and  contraction,  and  by  the  bubbling  of  gas  through 
it.  The  condition  is  one  of  some  importance,  as  it  may 
lead  to  the  suspicion  of  gastric  cancer.  Thus  I  saw  with 
Dr.  Salzer,  in  September,  1892,  a  woman  aged  thirty-two,  a 
chronic  dyspeptic,  but  who  lately  had  had  very  severe 
symptoms,  and  had  lost  rapidly  in  weight,  having  fallen 
from  ninety-five  to  sixty  pounds.  At  the  junction  of  the 
epigastric  and  umbilical  regions,  a  little  to  the  left  of  the 
middle  line,  there  was  a  soft,  cylindrical  structure,  which 
descended  with  inspiration.  Its  transverse  extent  was  not 
more  than  three  or  four  centimetres.  It  hardened  definitely 
under  palpation.  Gas  was  felt  escaping  through  it.  The 
patient  was,  of  course,  extremely  emaciated,  and  the  dis- 
covery of  the  tumor,  together  with  the  pronounced  stomach 
symptoms,  led  to  a  suspicion  of  malignant  disease.  The 
case  was  subsequently  under  my  care  for  seven  months, 
and  proved  to  be  an  extremely  obstinate  form  of  anorexia 
nervosa ;  but  she  gained  in  weight  from  sixty  to  a  hun- 
dred and  fifteen  pounds,  and  the  improvement  continues  to 
date. 

I  believe  that  in  very  thin-walled  persons,  particularly 
those  with  atony  of  the  stomach,  the  pylorus,  i,  e.,  the  ring 
and  adjacent  part,  may  sometimes  be  felt  as  a  narrow,  tu- 


38  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

bular  structure,  the  distinguisliing  features  of  which  are 
the  alternate  relaxation  and  contraction  and  the  bubbling 
of  gas  through  it. 

Of  the  seventeen  cases,  two  were  instances  of  cicatricial 
thickening  and  stenosis,  and  in  fifteen  there  was.  either  a 
cylindrical  tumor  or  a  nodular  mass. 

A  tumor-like  formation  at  the  pylorus  may  be  due  to  a 
number  of  causes — cicatricial  contraction  and  thickening 
about  an  ulcer,  hypertrophy  of  the  pylorus,  and  cancerous 
growths — all  of  which  conditions  may  lead  to  stenosis  of 
the  orifice  and  secondary  dilatation  of  the  stomach.  Again, 
the  first  part  of  the  duodenum  and  the  pylorus  may  be  in- 
vaded by  growths  from  contiguous  organs,  as  in  a  case  to 
be  subsequently  mentioned,  in  which  the  tumor  in  the  py- 
loric region  was  caused  by  invasion  of  the  duodenum  by  a 
cancer  of  the-  colon.  And,  lastly,  there  may  be  mentioned 
as  a  cause  of  dilatation  of  the  stomach,  stenosis  of  the  py- 
lorus by  dislocation.  Thus  adhesions  may  form  between 
the  gall  bladder  and  the  pylorus,  and  this  portion  of  the 
organ  is  drawn  up  and  the  orifice  narrowed.  A  remarkable 
instance  of  the  kind  was  operated  upon  in  the  hospital  by 
Dr.  Finney  in  August  last. 

Tumors  of  the  pylorus  are  usually,  but  not  always,  asso- 
ciated with  dilatation;  thus  there  were  only  four  out  of 
the  seventeen  cases  in  which  the  organ  was  not  distended. 
The  cases  of  pyloric  growths  or  thickening  may  be  grouped 
as  follows : 

Thickening  and  Induration  from  Healing  of  an  Ulcer. — 
Two  cases  come  in  this  category — Case  X  of  the  series 
already  given  in  the  first  lecture,  which  presented  a  very 
greatly  dilated  stomach.  There  was  a  ridge-like  mass, 
freely  movable,  to  be  felt  midway  between  the  umbilicus 
and  the  right  costal  margin.  The  prolonged  history  of 
dyspepsia,  the  moderate  wasting,  the  fact  that  she  had  on 
several  occasions  vomited  blood,  and  the  small  size  of  the 


NODULAR  AND   MASSIVE   TUMORS  OF  THE  STOMACH.    39 

pyloric  tTimor,  suggested  cicatrization  about  an  ulcer.  In 
the  following  case  gastro-enterostomy  was  performed  by 
Dr.  Finney,  and,  unfortunately,  on  the  tenth  day  the  pa- 
tient died  of  an  acute  colitis.  The  nodular  tumor  was  very 
well  defined,  particularly  after  the  stomach  had  been  emp- 
tied. 

Case  XII.  Dilated  Stomach;  Tumor  Mass  at  the  Pylorus; 
Gastro-enterostomy;  Autopsy ;  Stenosis  from  Ulcer.— Mary  G. 
aged  twenty-two,  colored,  admitted  on  July  29th,  complaining  of  a 
"gnawing  in  the  stomach"  and  "vomiting  spells."  Family  his- 
tory good.  Was  healthy  as  a  young  girl,  with  the  exception  of  a 
slight  attack  of  pneumonia  about  eight  years  ago,  and  malaria  a 
year  later. 

Her  present  illness  began  last  April  with  loss  of  appetite  and 
weakness,  and  she  began  to  lose  flesh.  About  two  months  ago  she 
noticed  a  lump  in  the  abdomen,  which  she  thinks  has  got  larger. 
About  this  time  she  began  to  vomit  at  irregular  intervals,  without 
any  nausea  or  acid  eructations.  The  attacks  gave  her  relief,  and 
she  says  the  lump  seemed  smaller  after  them.  The  vomitus  was 
copious,  greenish  in  color,  and  watery.  Bowels  have  been  con- 
stipated. The  feet  have  swollen  sometimes.  She  has  never  vomited 
blood. 

Condition  on  Adm^■ss^on■.— Medium-sized,  greatly  emaciated, 
lips  and  mucous  membranes  pale,  tongue  presents  a  whitish  fur. 
Pulse  92,  regular,  of  fair  volume.  With  the  exception  of  a  soft 
systolic  murmur  at  the  heart  apex,  there  are  no  abnormal  physical 
signs  in  the  thoracic  organs.  The  abdomen  is  symmetrical,  not 
specially  distended.  In  the  right  hypochondrium,  just  below  the 
costal  margin  and  opposite  to  the  cartilage  of  the  eighth  rib,  there 
is  a  small  nodule,  apparently  the  size  of  a  horse-chestnut,  which 
descends  with  inspiration  and  gives  tbe  impression  of  being  at 
tbe  pyloric  orifice.  It  varies  somewhat  in  position  and  in  firm- 
ness ;  thus  the  day  on  which  I  examined  her  (September  1st)  it 
could  by  no  means  be  satisfactorily  determined,  although  the  day 
before  Dr.  Thayer  had  been  able  to  feel  it  with  the  greatest  distinct- 
ness. On  inflating  the  stomach,  the  area  of  gastric  tympany  was 
found  to  be  greatly  increased,  extending  from  the  fifth  rib  above 


40  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

fully  three  fingers'  breadth  below  the  umbilicus.  During  great  dis- 
tention of  the  stomach  the  nodular  mass  could  not  be  felt.  The 
material  obtained  after  a  test  breakfast  was  mixed  with  fragments 
of  undigested  bread  and  curds  of  milk  which  had  been  taken  the 
day  before.  It  has  a  strong  sour  smell,  suggesting  butyric  acid. 
The  reaction  was  acid.  The  congo  and  tropaeolin  tests  were  nega- 
tive.    Uffelman's  test  gave  sharply  positive  results. 

After  treatment  for  some  time  with  washing  out  the  stomach  no 
special  benefit  followed,  and,  as  the  lesion  seemed  most  probably 
stenosis  from  ulcer,  it  was  thought  advisable  to  attempt  dilatation. 
Accordingly,  Dr.  Finney  made  an  exploratory  examination  and 
found  externally  much  thickening  about  the  pylorus.  He  opened 
the  stomach  on  the  anterior  wall,  and,  exploring  digitally,  found 
the  orifice  much  narrowed,  partly  by  contraction,  partly  by  poly- 
poid excrescences,  several  of  which  were  removed.  As  it  was 
doubtful  whether  this  would  be  sufficient,  a  communication  was 
made  between  the  stomach  and  the  jejunum.  The  patient  did  very 
well  for  ten  days,  but  then  vomiting  and  diarrhoea  set  in  and  the 
latter  became  severe  and  she  died  in  the  third  week  after  the  opera- 
tion. 

The  post-mortem  showed  chronic  adhesive  peritonitis  about  the 
pylorus  and  over  the  surface  of  the  liver.  The  jejunum  was 
very  firmly  adherent  to  the  anterior  wall  of  the  stomach.  The 
tumor  mass  which  had  been  felt  during  life  was  the  thickened 
pylorus.  When  laid  open,  a  large  ulcer  was  found  in  the  pyloric 
region  with  much  puckering  of  the  mucosa  about  it  and  cicatricial 
contraction. 

Tubular  and  Small  Nodular  Tumors  at  the  Pylorus.— 
Next  let  me  call  your  attention  to  four  cases  which  have 
presented  a  good  deal  of  difficulty  in  diagnosis,  not  as  to 
the  existence  of  the  tumors,  but  as  to  their  nature.  In 
three  there  was  a  cylindrical,  somewhat  tubular-shaped 
tumor  to  be  felt.  In  two  of  them  there  was  evidence  of 
some  dilatation  of  the  organ  after  inflation,  but  the  symp- 
toms in  each  case  were  those  of  chronic  dyspepsia,  not  of 
extreme  dilatation  of  the  stomach.  I  will  first  read  you 
the  report  of  the  cases. 


NODULAR  AND  MASSIVE  TUMORS  OP  THE  STOMACH.    41 

Case  XIII.  Chronic  Dyspepsia;  Cylindrical  Tumor  of  the 
Pylorus. — Mr,  S.,  aged  seventy  years,  was  admitted  to  Ward  C 
October  6th,  complaining  of  dyspepsia. 

The  patient  has  been  a  dyspeptic  ever  since  1843,  and  unless 
very  careful  with  his  diet  had  fullness  and  tenderness  in  the 
epigastrium.  He  frequently  had  very  disagreeable  feelings  after 
eating,  and  would  vomit  or  regurgitate  the  food.  In  spite  of  the 
dyspepsia,  he  has  always  been  robust  and  has  never  been  laid  up 
in  bed.  For  the  past  two  years  the  dyspepsia  has  been  more 
troublesome  and  he  has  frequently  had  pain  after  eating.  The 
gastric  trouble  increased  so  much  that  four  months  ago  he  had  to 
take  peptonized  milk.  There  has  been  no  vomiting,  though  at  any 
time  he  could  regurgitate  the  food.  For  the  past  ten  months  he 
has  lost  in  weight  (as  much  as  twenty  pounds)  and  in  strength, 
and  has  been  in  very  low  sijirits. 

The  patient  is  a  well-preserved  man  for  his  years,  of  spare 
habit,  but  neither  emaciated  nor  cachectic.  The  general  physical 
examination  is  negative.  The  heart,  arteries,  and  lungs  are 
normal. 

Abdomen  flat,  on  palpation  soft,  no  pain.  Four  centimetres 
above  the  navel  there  is  to  be  felt  a  ridge-like  tumor,  which  can  be 
rolled  beneath  the  fingers,  and  which  extends  six  centimetres  in 
the  transverse  direction.  On  inspiration  it  descends  slightly.  It 
can  be  moved  up  and  down ;  the  surface  is  smooth,  and  firm  pres- 
sure is  not  painful.  The  point  of  greatest  interest  is  the  remark- 
able variability  in  consistence  within  a  few  minutes.  At  times  it 
is  firm,  hard,  and  ridge-like,  and  within  a  minute  it  becomes  very 
much  softer.     Gas  can  be  felt  to  bubble  through  it. 

There  is  no  glandular  enlargement.  After  a  test  breakfast 
sixty  cubic  centimetres  of  a  light  greenish  fluid,  rather  slimy  and 
mucoid,  were  removed,  which  gave  none  of  the  reactions  for  free 
hydrochloric  acid. 

Patient  left  hospital  on  October  22d,  somewhat  better,  but  I 
hear  from  Dr.  H.  M.  Thomas  that  he  died  before  Christmas. 

Case  XIV.  Dyspepsia  of  a  Yearns  Duration;  Cylindrical 
Tumor  of  Pylorus. — Bertha  N.,  aged  forty-four,  admitted  to  Ward 
G,  October  28th,  complaining  of  pain  in  the  epigastric  region  and 
loss  of  appetite. 


42  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

Father  died  of  tuberculosis ;  motlier  of  haemorrhage  from  the 
uterus.     She  has  had  two  healthy  children. 

Her  present  illness  is  of  more  than  a  year's  duration.  She  has 
had  weakness,  loss  of  flesh,  and  for  several  months  the  appetite  has 
been  very  poor.  She  gives  an  account  of  what  she  calls  spasms, 
which  would  appear  to  be  fainting  flits  at  the  menstrual  period. 
After  eating  she  has  pain  and  has  to  lie  down,  and  finds  relief  by 
pressure  on  the  abdomen.  There  has  been  no  vomiting.  Lately 
she  has  lived  principally  on  milk. 

Present  Condition. — There  is  uniform  pigmentation  of  the  face 
except  in  one  or  two  spots  on  the  cheeks  and  chin.  The  general 
pigment  over  the  surface  of  the  body  seems  to  be  somewhat 
increased,  particularly  on  the  abdomen  and  the  arms.  She  is 
decidedly  emaciated,  but  the  lips  are  of  a  red  color,  and  she  has  not 
a  cachectic  look.  The  tongue  is  furred.  The  examination  of  the 
thoracic  organs  is  negative.  The  heart  sounds  are  clear.  The 
superficial  arteries  are  slightly  thickened. 

The  abdomen  is  flat,  somewhat  sunken,  walls  relaxed.  In  the 
epigastrium,  a  little  below  the  ensiform  cartilage  and  extending 
into  the  right  hypochondriac  region,  a  cylindrical  tumor  can  be 
felt  and  rolled  beneath  the  flngers ;  at  intervals  gas  can  be  felt  to 
bubble  through  it.  The  inflation  of  the  stomach  shows  the  organ 
to  be  depressed  and  somewhat  dilated. 

An  hour  after  a  test  breakfast  there  was  very  little  material 
obtained.  It  was  acid  to  litmus  paper  ;  no  reaction  to  congo  paper. 
On  washing  out  the  stomach,  two  or  three  lumps  of  bread,  not 
digested,  were  obtained.  There  was  no  free  hydrochloric  acid. 
Subsequent  examinations  showed  persistence  of  this  ridge-like  mass 
in  the  epigastrium,  but  it  varied  considerably  in  position ;  thus  on 
November  4th  it  could  be  felt  distinctly  to  the  left  of  the  middle 
line,  and  even  a  ridge  beneath  the  skin  could  be  seen  in  this  posi- 
tion to  descend  on  deep  inspiration.  The  patient  left  the  hospital 
December  22d,  and  has  not  since  reported  for  examination. 

Case  XV.  Dyspepsia  for  Several  Years ;  Cylindrical  Tumor 
of  the  Pylorus. — M.  O.,  aged  fifty -four  years,  admitted  March  10, 
1893,  complaining  of  pain  in  the  stomach.  Father  died  at  sixty- 
two  of  pulmonary  tuberculosis,  of  which  disease  also  one  brother 
died.    Mother  died  at  sixty-flve  of  dropsy. 


MODULAR  AND  MASSIVE  TUMORS  OF  THE  STOMACH.    43 

Slie  lias  always  been  healthy  ;  married  ;  has  three  children. 
Has  been  subject  to  dyspepsia  for  several  years. 

Last  winter  she  had  a  great  deal  of  pain  in  the  epigastrium, 
diarrhoea,  and  vomiting  of  a  greenish  fluid.  She  was  in  hospital 
for  eleven  weeks,  but  improved,  and  from  July  of  last  year  until 
January  she  was  perfectly  well  and  could  eat  anything,  but  she  has 
been  paler  and  more  sallow  and  has  lost  in  weight. 

The  present  trouble  began  about  four  weeks  ago  with  pain  in 
the  epigastrium  and  great  tenderness.  She  has  had  nausea,  but  no 
vomiting.  The  patient  is  a  small  woman,  looks  ill,  complexion 
very  sallow,  lips  and  mucous  membranes  pale.  Tongue  is  flabby 
but  clean.  With  the  exception  of  a  soft  murmur  at  the  apex  of 
the  heart,  examination  of  the  thoracic  organs  is  negative. 

The  abdomen  is  a  little  full,  everywhere  tympanitic.  There  is 
a  marked  depression  just  below  the  costal  margin  on  both  sides  ; 
no  peristalsis  visible.  Palpation  at  first  caused  so  much  tenderness 
that  the  examination  was  unsatisfactory ;  but  as  she  drew  a  deep 
breath  a  small  nodular  mass  could  be  felt  descending  beneath  the 
ribs  in  the  parasternal  line.  In  a  few  days  she  was  somewhat 
better,  and  a  more  thorough  examination  could  be  made.  In  the 
parasternal  line,  midway  between  the  costal  margin  and  the  navel, 
there  is  a  cylindrical  mass,  transversely  placed,  which  can  be  rolled 
beneath  the  fingers.  It  is  extremely  sensitive;  no  flatus  is  felt 
passing  through  it.  On  deep  inspiration,  it  descends  and  the 
fingers  can  be  placed  above  it  so  as  to  hold  it  down.  On  percus- 
sion, it  is  resonant.  After  inflation  of  the  stomach  there  is  no 
marked  dilatation  of  the  organ  ;  no  peristalsis  is  seen,  but  the 
tumor  is  then  not  so  easily  palpable. 

Ewald's  test  breakfast,  withdrawn  fifty  minutes  afterward, 
showed  about  fifty  cubic  centimetres  of  grayish,  slimy  fluid,  con- 
taining portions  of  undigested  food,  and,  on  testi;:g,  no  free  hydro- 
chloric acid. 

Patient  was  under  observation  until  May  11th.  The  tumor  did 
not  change  in  any  way.  The  pain  lessened  and  she  gained  in 
weight  from  a  hundred  and  seventeen  pounds  on  admission  to  a 
hundred  and  twenty-five  pounds  on  discharge. 

Case  XVI.  Nodular  Tumor  in  the  Pyloric  Region;  Dilatation 

of  Stomach.— 3.  A.  R.,  Talbot  County,  Md.,  seen  October  19,  1892, 
6 


44 


THE  DIAGNOSIS  OF  ABDOMINAL  TUMOES. 


with  Dr.  Chamberlaine.    The  patient  had  been  admitted  to  Ward 
C,  November  17,  1891,  with  the  following  history: 

For  ten  months  he  had  had  occasional  paroxysms  of  boring  pain 
in  the  abdomen,  coming  on  usually  at  night.  Six  months  previous 
to  admission  he  had  noted  a  small  nodular  tumor  in  the  abdomen, 
which  he  says  has  gradually  become  larger.  He  has  had  no  symp- 
toms of  indigestion  or  special  distention  of  the  stomach  after  eat- 
ing ;  has  vomited  only  twice,  on  both  occasions,  he  thinks,  caused 
by  a  severe  paroxysm  of  pain.  He  has  lost  about  fourteen  pounds 
in  the  past  month.  He  was  a  man  of  spare  habit,  but  was  not 
anaemic.  A  test  breakfast,  withdrawn  an  hour  after  the  meal, 
showed  about  two  ounces  of  fluid  containing  small  lumps  of  partly 
digested  food.    Free  hydrochloric  acid  was  present. 

In  the  abdomen,  just  above  and  to  the  right  of  the  umbilicus, 
there  was  felt  a  rounded  tumor  about 
the  size  of  an  English  walnut,  freely 
movable.  On  inflation,  the  stomach 
tympany  extends  two  fingers  breadth 
below  the  umbilicus. 

The  patient  remained  in  hospital 
for  a  couple  of  weeks ;  had  no  special 
gastric  symptoms,  gained  in  weight, 
and  returned  to  his  home  November 
27th.  The  case  was  regarded  as  one 
of  tumor  of  the  pylorus,  and  he  was 
told  if  the  trouble  increased  an  oper- 
ation might  be  advisable. 

October  19,  259;?.— Patient  exam- 
ined to-day ;  has  been  very  much  bet- 
ter; entirely  free  from  pain ;  has  had 
no  vomiting;  has  been  taking  an  or- 
dinary diet;  no  nausea;  no  sense  of 
distress  after  eating.     He  looks  and  feels  well. 

The  abdomen  is  a  little  full  in  the  umbilical  region,  flat  in  the 
epigastric.  It  is  everywhere  soft  and  painless  ;  nothing  can  be 
felt  in  the  epigastric  region.  Midway  between  the  navel  and  right 
costal  margin  there  is  the  same  well-defined,  firm,  hard  nodule  to 
be  felt,  which  is  now  painless.     It  descends  with  inspiration  and 


Fig.  13.— Positions  into  which  the 
tumor  could  be  moved  in  Case 
XVI. 


NODULAR  AND   MASSIVE   TUMORS  OF   THE  STOMACH.    45 

can  be  moved  about  in  the  positions  noted  in  the  diagrams.  The 
patient  says  that  it  is  not  nearly  so  evident  when  the  stomach  is 
empty.  It  is  prominent  enough  to  be  seen  when  the  skin  is  pressed 
over  it.  It  can  be  pushed  far  up  under  the  right  costal  mar- 
gin and  at  first  could  not  be  felt,  as  it  was  high  in  this  position 
and  only  made  to  descend  by  deep  inspiration.  To  the  left  it  can 
be  pushed  beyond  the  middle  line  to  a  point  midway  between  the 
navel  and  the  left  costal  margin.  It  is  very  mobile.  On  inflation 
of  the  stomach  the  lower  border  was  found  to  descend  some  dis- 
tance below  the  umbilicus — three  or  four  fingers'  breadth — while 
the  lesser  curvature  was  almost  as  low  as  the  umbilicus.  When 
the  stomach  was  inflated  the  mass  could  not  at  first  be  felt,  but 
afterward  was  found  a  trifle  more  to  the  right  and  not  appar- 
ently quite  so  superflcial  as  it  was  before  the  distention.  Nearly 
a  year  has  elapsed  since  this  patient  left  the  hospital  ;  in  that 
time  the  nodular  tumor  has  increased  but  little  in  size,  and  the 
patient's  general  condition  is  remarkably  good. 

In  Cases  XIII,  XIV,  and  XV  tlie  tumor  had  a  defi- 
nitely cylindrical  shape,  and  in  Case  XIII  there  seemed  to 
be  no  question  that  the  tumor  was  a  thickened  pylorus,  as 
marked  variations  occurred  in  its  consistence  and  gas 
could  be  felt  bubbling  through  it.  So  also  in  Case  XIV 
similar  features  seemed  to  indicate  clearly  that  the  tubular 
structure,  so  readily  felt,  represented  in  reality  the  thick- 
ened pyloric  ring  and  adjacent  part  of  the  stomach.  In 
Case  XVI  the  tumor  was  rounded,  nodular,  and  very 
movable.  It  did  not  vary  in  consistence  and  no  gas  was 
felt  to  bubble  through  it.  It  felt  very  hard  and  firm. 
While  its  local  features  seemed  to  indicate  definitely  that  it 
was  a  new  growth,  the  general  condition  of  the  patient 
after  its  existence  for  eighteen  months  seemed  to  be  very 
much  against  the  view  that  it  was  cancer.  Scirrhus,  how- 
ever, may  develop  very  slowly  indeed  at  the  pylorus,  and 
make  very  slight  progress  within  six  months.  Thus  in 
Case  XVII,  on  the  first  admission  in  September,  after  an 
illness  of  fifteen  months'  duration,  the  pyloric  tumor  con- 


46  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

stituted  a  tubular,  sausage-like  tumor,  wliicli  could  be 
rolled  beneath,  the  finger.  I  frequently  discussed  with 
Dr.  Thayer  the  question  whether  it  was  an  instance  of 
hypertrophic  thickening  of  the  pylorus  or  a  scirrhus 
growth,  and  the  time  element  seemed  to  be  in  favor  of 
the  former ;  but  when  the  patient  returned  in  April  of  this 
year  the  tumor,  which  meantime  had  increased  in  size,  was 
found  to  be  a  scirrhus.  The  hypertrophic  stenosis,  with 
which  the  annular  scirrhus  of  the  pylorus  could  alone  be 
confounded,  occurs  in  connection  with  chronic  gastritis, 
with  scars  of  old  ulcers,  in  connection  with  a  cirrhosis  in 
other  parts  of  the  stomach  or  intestines,  and  sometimes 
with  a  general  sclerosis  of  the  tissues  of  the  mesentery 
and  peritonaeum.  It  may  be  impossible,  for  a  time,  to 
give  a  positive  opinion.  In  either  case,  however,  the  con- 
dition is  serious. 

Cases  of  Large  Nodular  Growths  at  the  Pylorus.— These 
constitute  a  large  majority  of  pyloric  tumors.  Most  of 
the  cases  have  already  been  described  in  the  first  lecture 
in  connection  with  the  dilatation  of  the  stomach.  In  some 
the  tumor  itself  was  visible  beneath  the  skin.  The  fol- 
lowing cases  are  good  illustrations  of  this  type  of  growth. 
In  one  the  tumor  was  an  annular  cancer,  which  was  re- 
moved by  operation : 

Case  XVII.  Annular  Carcinoma  of  the  Pylorus ;  Excision  of 
Growth;  Death;  Autopsy.— Heury  M.,  aged  sixty-one  years, 
laborer,  admitted  September  30th,  complaining  of  "  sour  stomach  " 
and  vomiting. 

No  history  of  hereditary  disease.  Patient  has  been  healthy 
and  strong,  and  has  had  only  a  few  illnesses.  He  has  used  alco- 
hol freely,  but  has  not  been  a  heavy  drinker. 

Present  illness  began  fifteen  months  ago  with  an  uneasy  feel- 
ing in  the  abdomen  and  churning  sensations,  which  continued 
until  he  vomited  a  watery,  very  bitter  fluid,  which  sometimes  had 
a  greenish-yellow  color.     At  first  his  appetite  and  digestion  re- 


NODULAR  AND  MASSIVE  TUMORS  OF  THE  STOMACH.    47 


mained  good.  The  uncomfortable  feelinir  after  eating  gradually 
increased,  and  during  the  past  five  months,  although  his  appetite 
has  been  good  and  he  took  his  regular  meals,  vomiting  came  on 
about  an  hour  and  a  half  afterward.  He  has  never  brought  up 
very  large  quantities,  and  pain  has  never  been  a  prominent  fea- 
ture. He  has  lost  weight  rapidly,  and  within  six  months  has 
fallen  from  a  hundred  and  fifty  to  a  hundred  and  fourteen  pounds. 
The  bowels  have  been  very  irregular,  and  he  sometimes  has  had  no 
movements  for  a  week  or  ten  days,  and  recently  has  gone  as  long 
as  sixteen  days. 

Present  Condition. — Large  framed  man  ;  much  emaciated,  par- 
ticularly in  the  face.  The  cheek  bones  are  prominent  and  the 
eyes  sunken.  The  mucous  membranes  are  not  specially  anasmic, 
and  the  facies  can  scarcely  be  termed  cachectic.  The  emaciation 
is  marked  about  the  thorax  ;  the  skin  is  smooth  and  clean  ;  super- 
ficial lymph  glands  are  not  involved. 
The  tongue  is  a  little  swollen,  indented, 
and  furred. 

The  abdomen  is  flat,  very  much  be- 
low the  level  of  the  costal  margin. 
There  is  a  slight  prominence  just  to 
the  right  of  the  navel,  and  on  deep  in- 
spiration a  ridge-like  mass  descends 
below  the  point. 

On  palpation,  there  can  be  felt  just 
above  and  extending  to  the  right  of  the 
navel  a  firm  mass  which  descends  on 
inspiration  and  can  be  rolled  beneath 
the  fingers,  giving  one  the  impression 
of  a  tubular,  sausage-like  tumor.  On 
deep  inspiration,  it  moves  down  nearly 
three  inches  and  can  be  readily  held  at 
the  navel,  and  then  slips  away  from  be- 
neath the  fingers. 

The  patient  was  placed  upon  a  careful  diet  of  milk  and 
Qgg  albumin,  upon  which  the  nausea  disappeared  and  he  be- 
came very  much  more  comfortable.  The  examination  on  the 
17th  showed    that   the   elongated    mass    above   referred    to   had 


Fig.  14.— a,  position  of  the  tumor 
in  expiration  ;  6,  in  inspira- 
tion. 


48  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

changed  in  position  and  lay  to  the  left  of  and  just  ahove  the 
navel. 

The  liver  is  not  enlarged  ;  the  edge  of  the  spleen  is  not  pal- 
pable. 

The  patient  got  dissatisfied  with  the  diet,  and  left  the  hospital 
October  17th,  though  he  seemed  to  be  considerably  improved. 

April  6,  1893. — Patient  returned  to  the  hospital,  having  had, 
in  the  space  of  nearly  six  months  which  has  elapsed  since  the 
last  note,  very  marked  gastric  symptoms  and  occasional  attacks  of 
vomiting  of  large  quantities  of  fluid.  He  has  lost  in  weight, 
though  he  does  not  look  much  more  emaciated  than  when  he 
left. 

Examination. — Abdomen  is  scaphoid  and  the  walls  held  rather 
rigidly.  Between  the  ensiform  cartilage  and  the  navel  the  solid 
rounded  tumor  present  in  September  can  be  felt  in  the  same  posi- 
tion, but  it  appears  definitely  to  have  increased  in  size.  It  can  be 
rolled  beneath  the  fingers,  and  part  of  it  at  least  varies  somewhat 
in  consistence,  becoming  harder  and  firmer.  The  stomach  is  mod- 
erately dilated,  and  when  inflated  with  gas  shows  distinct  peri- 
stalsis, and  then  the  tumor  is  not  nearly  so  evident. 

The  advisability  of  an  operation  was  suggested  to  the  patient  in 
the  autumn,  but  he  refused  ;  now  he  is  anxious  that  one  should  be 
performed. 

The  age,  the  profound  emaciation,  and  the  very  evident  increase 
in  the  size  of  the  tumor  suggested  cancer  rather  than  cicatricial 
contraction,  with  thickening  at  the  pylorus  ;  and  as  the  case  was 
a  desperate  one,  and  the  man's  condition  hopeless,  the  election  of 
operation  was  left  to  the  patient 

On  the  11th  Dr.  Halsted  operated  and  found  a  solid  annular 
growth  in  the  pylorus,  extending  for  about  seven  centimetres, 
reaching  to  the  orifice,  but  not  extending  into  the  duodenum. 
As  there  were  no  special  adhesions  and  no  nodules,  be  proceeded 
to  resect  the  growth,  which  was  done  successfully.  The  operation 
lasted  about  two  hours,  and  the  patient  was  very  much  ex- 
hausted ;  he  rallied  well  through  the  night,  and  seemed  very  com- 
fortable, but  failed  rapidly  on  the  12th  and  died  on  the  13th. 

Case  XVIII.  Cancer  of  the  Stomach ;  Large  Tumor  in  the 
Pyloric  Region. — Patrick  K.,  aged  twenty-eight  years,  admitted 


NODULAR  AND  MASSIVE  TUMORS  OF  THE  STOMACH.    49 


to  "Ward  E,  January  3,  1S93,  complaining  of  pain  in  the  abdomen. 
Patient  had  been  an  orderly  in  the  hospital  in  1889-'91,  during 
which  time  he  was  laid  up  on  several  occasions — once  in  Decem- 
ber, 1889,  with  vomiting  and  diarrhoea  ;  again  in  April,  1890,  with 
acute  gastritis,  an  attack  associated  with  much  pain  ;  and  in  April, 
1891,  he  had  a  sharp  attack  of  amygdalitis.  A  very  noticeable 
feature  was  the  persistent  anaemia,  and  on  several  occasions  in  1889 
and  1890  I  had  examined  his  blood,  which  presented  all  the  char- 
acters of  a  secondary  anaemia  of  moderate  grade.  From  his  ear- 
liest boyhood  he  has  been  subject  to  nose-bleeding,  and  has  always, 
he  says,  been  pale. 

In  October,  1891,  he  returned  to  his  home  in  Ireland,  and  re- 
mained fairly  well,  but  was  troubled  on  several  occasions  with 
epistaxis.  He  returned  to  this  country  last  year.  Four  months 
ago  he  had  an  attack  of  pain  in  the 
abdomen  with  vomiting,  and  these 
symptoms  have  persisted  ever  since. 
The  vomiting  is  chieiiy  after  taking 
food,  and  the  pain  is  also  most  se- 
vere at  this  time.  He  has  never  vom- 
ited blood.  Bowels  have  been  con- 
stipated. He  has  lost  in  weight,  he 
thinks,  as  much  as  fourteen  pounds. 
He  is  short  of  breath  on  exertion, 
and  when  he  walks  about  for  any 
length  of  time  the  feet  and  ankles 
swell. 

Present  Condition. — He  is  very 
anaemic,  but  not  emaciated;  his  face 
is  full ;  blood  count,  3,000,000 ;  haemo- 
globin, thirty  per  cent. ;  eyelids  a  lit- 
tle puffy ;  hands  very  pale ;  pulse,  87, 
soft,  compressible;  radials  a  little  thickened;  vessels  of  neck  throb; 
the  heart  sounds  are  loud  and  clear  at  the  apex,  the  second  very 
ringing  and  accentuated  at  the  base ;  no  murmur.  The  examination 
fo  the  lungs  was  negative. 

Abdomen  full  and  a  little  prominent;  on  palpation,  everywhere 
soft  and  painless  until  the  right  epigastric  region  is  reached.    Here, 


Fig.  15.— Situation  of  the  tumor  in 
Case  XVIII. 


50  THE  DIAGNOSIS  OP  ABDOMINAL  TUMORS. 

under  the  costal  border  in  the  parasternal  line,  there  is  a  resistant 
mass  which  extends  to  the  right  almost  as  far  as  the  middle  line 
and  to  the  left  as  far  as  the  nipple  line,  and  below  at  least  six  cen- 
timetres from  the  costal  border.  During  a  deep  inspiration  the 
mass  descends  and  the  fingers  can  then  be  placed  between  it  and 
the  costal  margin.  In  the  middle  line  in  the  epigastric  region 
nothiug  is  palpable.  There  is  resonance  over  the  above-described 
tumor  mass.  There  is  no  peristalsis  apparent;  no  gurgling  to  be 
felt  in  the  mass.  After  dilatation  of  the  stomach  the  tympany  in 
the  parasternal  line  was  at  the  seventh  rib,  and  extended  two  fin- 
gers' breadth  below  the  navel.  The  tumor  was  piished  far  over 
neai'ly  beyond  the  nipple  line. 

A  test  breakfast  withdrawn  an  hour  after  gave  a  hundred  and 
twenty  cubic  centimetres  of  thick,  dark-brown  fluid,  containing  un- 
digested food  and  a  few  shreds  of  clotted  blood.  The  reaction  was 
acid ;  there  was  no  reaction  with  congo  paper,  nor  with  the  other 
tests  for  free  hydrochloric  acid.  Uffelman's  test  for  lactic  acid  was 
positive;  starch  test  negative.  The  spleen  was  not  enlarged;  the 
liver  not  enlarged.     The  urine  presented  no  changes. 

The  patient  failed  rapidly,  became  very  anaemic,  and  lost  sixteen 
pounds  in  weight  within  a  month.  The  vomiting  was  very  trouble- 
some and  intractable.  No  special  change  took  place  in  the  charac- 
ter of  the  tumor  mass,  though  as  he  became  thinner  it  was  rather 
more  evident.  He  died  on  February  23,  1893.  There  was  no  au- 
topsy. 

Practically,  then,  the  tumors  at  the  pyloric  orifice  which 
we  have  been  studying  consisted  of  cicatricial  thickening 
caused  by  ulcer,  possibly  hypertrophic  stenosis,  annular 
carcinoma,  and  large  nodular  masses.  There  are  one  or 
two  points  of  general  interest  to  which  I  will  here  refer. 
In  the  first  place,  the  tumor  is  always  larger  than  you  ex- 
pect from  the  examination  through  the  abdominal  wall. 
This  has  to  be  borne  in  mind  in  a  discussion  on  the  advisa- 
bility of  operation.  It  is  frequently  very  variable — well 
and  plainly  to  be  felt  to-day,  and  perhaps  scarcely  palpa- 
ble to-morrow — variations  which  depend  a  great  deal  upon 


NODULAR  AND   MASSIVE   TUMORS   OF  THE  STOMACH.    51 

the  degree  of  dilatation  of  the  organ,  particularly  of  the 
portion  known  as  the  pyloric  pouch,  which  may  cover  over 
and  mask  even  a  large  pyloric  tumor.  Examination  in 
the  knee-elbow  position  often  gives  valuable  information  as 
to  the  relations  and  positions  of  a  tumor,  and  should  never 
be  omitted  in  doubtful  cases.  The  value  of  careful  palpa- 
tion with  a  view  of  determining  whether  gas  bubbles  through 
the  tumor  is  of  the  very  greatest  importance.  The 
masses  are  usually  firm,  hard,  and  often  of  a  stony  consist- 
ence ;  sometimes  the  nodular  masses  formed  by  the  glands 
in  the  neighborhood  of  the  pylorus  can  be  very  plainly  felt. 
A  feature  in  the  pyloric  tumor  which  merits  special  at- 
tention is  the  mobility.  I  have  already  referred  to  it 
in  Case  V,  in  which  the  solid  rounded  tumor  mass  could 
be  pushed  beneath  the  ribs  on  the  right  side,  far  down 
into  the  iliac  regions,  and  far  over  to  the  left  costal 
border.  So  also  the  nodular  tumor  in  Case  XVI,  which 
I  have  just  read  to  you,  was  extremely  movable.  I  re- 
ported a  case  a  few  years  ago  ( University  Medical  Maga- 
zine, vol.  i,  p.  3G8)  which  is  of  great  interest  in  this  connec- 
tion : 

The  patient,  aged  sixty-five  years,  was  admitted  to  the  Philadel- 
phia Hospital,  October  14,  1888,  with  chills  and  fever.  The  blood, 
however,  was  negative,  and  it  was  ascertained  that  he  had  had  for 
some  weeks  distress  after  eating,  and  our  attention  was  then  di- 
rected to  a  more  careful  examination  of  the  abdomen.  On  Novem- 
ber 11th  the  following  note  was  made  :  Patient  is  anaemic  and 
emaciated;  the  abdomen  flattened;  there  is  a  prominent  projection 
below  the  left  costal  border  in  the  parasternal  line  reaching  nearly 
to  the  navel  and  descending  with  inspiration.  Palpation  reveals  a 
firm,  hard  mass,  occupying  the  left  hypochondriac  region  and  the 
left  half  of  the  epigastric  region.  It  is  smooth  and  not  painful,  and 
can  be  moved  from  side  to  side  to  an  extent  of  two  or  three  inches. 
Percussion  over  it  gives  a  flat  tympanitic  note ;  liver  dullness  not 
increased;  glands  in  the  groin  are  double  the  normal  size;  vomited 
matters  are  brownish  in  color,  acid,  but  contain  no  sarcinae.     The 


52  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

tumor  changed  curiously  in  position  from  day  to  day ;  at  one  time 
it  was  far  over  in  tlie  right  hypochondriac  region,  entirely  beyond 
the  middle  line,  but  more  commonly  a  greater  portion  of  its  extent 
was  in  the  left  hypochondriac  region.  On  several  occasions  it 
seemed  to  have  disappeared  altogether,  and  only  a  hard,  small  mass 
could  be  felt  far  over  in  the  left  hypochondrium.  Patient  sank 
gradually  and  died  November  20th.  When  the  abdomen  was 
opened  no  trace  of  tumor  was  visible  until  the  stomach  was  pulled 
down  and  to  the  right.  It  was  then  seen  that  the  mass  had  fallen 
back  into  the  left  hypochondriac  region  below  the  ribs,  where  it 
was  completely  covered  by  the  splenic  flexure  of  the  colon.  The 
duodenum  was  curiously  elongated  and  straightened ;  from  the  py- 
loric ring  it  measured  over  two  inches  as  a  straight  tube.  The  pan- 
creas was  also  drawn  over  to  the  left.  The  tumor  could  readily  be 
pushed  to  occupy  the  positions  in  which  it  was  felt  during  life.  It 
involved  the  anterior  wall  of  the  stomach,  which,  when  opened, 
presented  a  large  hemispherical  mass,  involving  three  fourths  of 
the  circumference  of  the  pyloric  region  and  extending  to  within  an 
inch  and  a  half  of  the  ring.  The  surface  of  the  mass  was  ulcerated, 
and  at  the  base  near  the  greater  curvature  suppuration  had  taken 
place. 

(5)  Tumors  of  the  Body  of  the  Stomach. — Tumors 
of  the  pyloric  region  often  encroach  extensively  on  the 
anterior  wall  of  the  stomach,  but  I  have  placed  in  this 
category  three  cases  in  which  the  tumor  mass  appeared  to 
be  more  in  the  central  part  of  the  organ.  In  Case  XIX 
the  left  epigastric  region  was  occupied  by  a  rounded, 
irregular  tumor,  and  the  patient  had  had  marked  gastric 
symptoms  and  had  vomited  blood.  Though  there  was  no 
question  as  to  the  nature  of  the  growth,  it  is  interesting 
to  note  that  during  his  stay  in  hospital  he  gained  six 
pounds  in  weight.  In  Case  XX  the  tumor  mass  was  more 
extensive  and  seemed  to  involve  a  large  section  of  the 
anterior  wall  of  the  stomach,  forming  a  very  prominent 
and  readily  palpable  tumor.  In  Case  XXI  a  large  nodular 
mass  could  be  felt  between  the  left  costal  margin  and  the 


NODULAR  AND  MASSIVE  TUMORS  OP  THE  STOMACH.    53 

navel.  It  was  unusually  firm,  and  post  mortem  showed 
that  it  occupied  more  than  ten  centimetres  of  the  anterior 
wall  of  the  stomach. 


Case  XIX.  Large  Tumor  of  the  Body  of  the  Stomach. — Gus- 
tave  P.,  a  shoemaker,  aged  fifty-three  years,  admitted  December  28, 
1892,  complaining  of  pain  in  the  abdomen  and  back. 

Parents  died  over  eighty  years  of  age  ;  one  sister  died  of  cancer 
of  the  womb. 

Patient  was  born  in  Germany  ;  has  been  very  healthy  ;  has  not 
been  a  heavy  drinker  ;  and  denies  lues. 

The  present  illness  he  dates  as  far  back  as  eight  years  ago,  at 
which  time  he  had  dyspeptic  symptoms,  which  persisted  for  two  or 
three  years  ;  then  he  remained  quite  free  from  them  for  about 
three  years,  but  early  in  1890  they 
recurred.  He  has  had  uneasy  sensa- 
tions after  meals,  and  belching,  some- 
times bringing  up  acid  fluid.  During 
the  past  summer  he  had  a  good  deal 
of  vomiting,  and  once  in  June  brought 
up  dark-brown  fluid,  which  was  said 
to  be  blood,  and  the  next  day  the  same 
material  was  noticed  in  the  stools. 
His  appetite  is  fair,  but  he  is  afraid 
to  eat,  and  lately  has  only  been  tak- 
ing liquids.  He  has  not  lost  very 
much  in  weight  —  only  about  five 
pounds  in  the  last  six  months. 

Present  Condition.  —  Patient  is 
emaciated,  pale,  and  a  httle  sallow  ; 
mucous  membranes  distinctly  an- 
aemic. Tongue  has  a  patchy  coating 
and  indented  edges.    Examination  of  the  thoracic  organs  is  negative. 

The  abdomen  is  symmetrical,  a  little  depressed  below  the  costal 
border  ;  no  peristalsis  visible.  On  palpation,  the  left  epigastric 
region  is  occupied  by  a  superficial  mass  with  a  rounded,  irregular, 
nodular  surface.  It  extends  sometimes  almost  to  the  middle  line, 
and  below  crosses  the  transverse  costal  line.     To  the  left  it  extends 


Fig.  16.— Outline  of  the  tumor  mass 
in  Case  XIX. 


54 


THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 


to  the  nipple  line.  It  is  a  little  painful  on  firm  pressure  ;  descends 
with  inspiration.  The  pulsation  of  the  aorta  is  transmitted  through 
it.  Percussion  gives  a  flat  tympany  over  the  mass.  Ewald's  test 
breakfast,  withdrawn  fifty-five  minutes  after,  yielded  about  seven 
hundred  cubic  centimetres  of  brownish  fluid  with  a  heavy  sedi- 
ment of  undigested  food  ;  odor  acid.  The  filtrate  turned  blue 
litmus  red,  congo  red  to  blue,  and  yielded  a  rose-red  color  with 
phloroglucin  vanillin.  Uffelman's  test  negative.  The  urine  was 
normal.  The  patient  remained  up  and  about  the  ward,  and  with  a 
careful  diet  was  made  much  more  comfortable.  The  condition  of 
the  gastric  juice  was  frequently  tested ;  thus  on  January  4th 
Ewald's  test  breakfast,  withdrawn  an  hour  later,  yielded  about 
five  hundred  cubic  centimetres  of  sour,  yellowish  food  matter, 
which  gave  the  reactions  previously  noted. 

The  patient  continued  to  improve,  gained   in  weight  from  a 
hundred  and  fourteen  to  a  hundred  and  twenty  pounds,  and  was  in 

every  way  more  comfortable.  He 
had  almost  constantly,  while  in  hos- 
pital, a  little  fever,  temperature  rising 
to  100°,  sometimes  to  101°,  every  day. 
No  special  change  occurred  in  the 
position  or  condition  of  the  tumor 
mass.  He  was  discharged  February 
27th,  and  has  not  since  been  heard 
from. 

Case  XX.  Tumor  of  the  Body  of 
the  Stomach. — N.  R.,  aged  sixty- 
nine,  shoemaker,  German,  came  to 
this  country  in  1872.  Admitted 
March  13th,  complaining  of  loss  of 
appetite,  nausea,  and  vomiting. 

Patient  was  sickly  as  a  child.  Six 
years  ago  he  had  a  fever  which  kept 
him  in  bed  for  three  weeks.  He  had 
been  a  moderate  drinker  ;  denies  syphilis.  Has  not  been  a  dys- 
peptic. 

Present  illness  began  before  Christmas  with  pain  after  eating, 
nausea,  and  vomiting,  the  latter  usually  a  short  time  after  taking 


Fia.  17.— Area  of  the  tumor  mass 
in  Case  XX. 


NODL^LAR  AND  MASSIVE  TUMORS  OP  THE  STOMACH.    55 

food.  The  appetite  has  failed  and  he  has  lost  rapidly  in  weight. 
He  has  had  much  fullness  and  distress  in  the  epigastric  region,  hut 
no  very  sharp  pain.  Of  late  all  these  symptoms  have  become 
aggravated.  He  has  never  had  vomiting  of  large  quantities  of 
food. 

Present  Condition. — Patient  is  a  large  man,  still  fairly  well 
nourished.  The  lips  and  mucous  membranes  are  pale ;  tongue  has 
a  thick  white  coat.  Pulse  is  regular,  64,  tension  slightly  increased 
the  vessel  wall  sclerosed.  Temperature  is  normal.  Examination 
of  the  thoracic  organs  is  negative. 

The  abdomen  is  symmetrical,  except  that  there  is  a  slight 
prominence  at  the  end  of  the  tenth  rib  on  the  left  side;  on  palpa- 
tion, soft,  and  nothing  is  felt  until  the  epigastric  region  is  reached. 
In  the  region  indicated  in  the  figure  is  a  mass  which  moves  freely 
in  inspiration.  The  lower  border  is  sharp  like  that  of  the  liver  or 
spleen ;  the  surface  is  irregular  and  somewhat  nodular.  On  per- 
cussion, there  is  a  distinct  tympany  over  the  mass.  On  inflation, 
there  is  no  abnormal  dilatation  of  the  stomach. 

Ewald's  test  breakfast  given  at  8  A.  M.  ;  at  9.30  a  tube  was 
inserted.  There  seemed  to  be  some  slight  obstruction  about  the 
cardiac  orifice,  and  about  fifty  cubic  centimetres  of  coflPee-colored 
fluid  removed,  together  with  a  very  little  fresh  blood.  There  was 
no  free  hydrochloric  acid.  Microscopically,  it  presented  fresh 
blood-cells,  blood-pigment,  and  remnants  of  food.  No  enlarge- 
ment of  the  lymph  glands. 

No  material  change  took  place  within  two  weeks  in  the  pa- 
tient's condition;  he  was  evidently  failing,  and  he  decided  to  go 
home. 

Case  XXI.  Tumor  of  the  Pyloric  Region  and  Anterior  Wall; 
Perforation;  Peritonitis. — August  B.,  aged  flfty-eight  years,  farm 
laborer,  German,  admitted  complaining  of  pain  in  the  abdomen, 
loss  of  appetite,  vomiting,  and  insomnia.  Father  died  aged  fifty- 
six,  cause  unknown;  mother,  of  dropsy  at  sixty;  one  sister  died  of 
cancer  of  the  stomach;  no  history  of  tuberculosis  in  the  family. 

Has  always  been  a  healthy  man;  the  father  of  seven  children. 
Has  been  a  moderate  drinker ;  denies  venereal  disease.  Has  always 
had  good  digestion ;  never  sufPered  from  dyspepsia. 

His  present  illness  began  four  weeks  ago  with  pain  in   the 


56  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

abdomen  and  vomiting,  which  comes  on  very  shortly  after  eating. 
He  has  never  vomited  any  great  quantities.  Though  he  does  not 
appear  to  have  had  any  marked  stomach  symptoms,  during  the 
past  six  months  he  has  lost  in  weight  from  a  hundred  and  sixty- 
five  to  a  hundred  and  thirty -five  pounds.  Patient  is  a  medium- 
sized  man,  pale,  thin,  lips  and  mucous  membranes  pale,  and  he 
looks  somewhat  cachectic.  Thorax  is  symmetrical ;  above  the  left 
clavicle  one  of  the  lymph  glands  is  enlarged  and  hard.  Examina- 
tion of  the  lungs  and  heart  negative. 

The  abdomen  is  full,  particularly  in  the  right  epigastric  region. 
Here,  on  palpation,  a  nodular  mass  can  be  felt  midway  between 
the  costal  margin  and  the  navel.  It  is  flat  and  extends  trans- 
versely as  far  as  two  cubic  centimetres  beyond  the  median  line. 
It  is  hard,  a  little  painful,  and  descends  with  each  inspiration.  It 
is  resonant  on  percussion.  No  peristalsis  was  felt,  no  changes  in 
consistence,  and  no  gas  was  felt  to  pass.  The  stomach  tympany 
begins  at  the  seventh  rib  in  the  left  parasternal  line  and  does  not 
quite  reach  the  navel.  After  inflation  of  the  organ  no  peristalsis 
is  seen. 

Test  breakfast  was  given  and  a  tube  inserted  an  hour  afterward. 
The  fluid  obtained  was  dark-brownish,  with  a  sour  odor;  contained 
organic  acids,  but  no  free  hydrochloric.  The  blood  count  showed 
lioemoglobin  forty-five  per  cent.,  and  the  red  blood-corpuscles  about 
four  million. 

The  patient  left  the  hospital  and  was  readmitted  April  12th,  and 
the  following  notes  were  made:  He  is  very  emaciated  and  looks 
cachectic.  There  is  a  marked  prominence  in  the  epigastric  region, 
just  below  the  ensiform  cartilage,  and  here  very  slight  irregular 
movements  may  be  seen.  The  indurated  mass  noted  above  appears 
to  have  increased  in  size.  It  lies  at  the  junction  of  the  umbilical 
and  epigastric  regions,  and,  on  inspiration,  descends  almost  to  the 
navel.  It  is  firm  and  resistant.  There  is  no  peristalsis  visible  after 
inflation  of  the  stomach,  and  no  change  in  the  position  of  the 
tumor.  Just  above  the  navel  in  the  linea  alba  there  is  to  be  seen  a 
flattened  prominence,  which  feels  soft  and  like  a  little  fatty  tumor 
beneath  the  skin.  Patient  became  progressively  weaker  and  died 
June  4th. 

Autopsy. — Peritoneal  cavity  contains  nine  hundred  cubic  centi- 


NODULAR  AND  MASSIVE  TUMORS  OF  THE  STOMACH,    57 

metres  of  turbid  fluid;  fibrinous  exudate  covers  the  intestines. 
There  is  a  large  tumor  mass  to  the  left  of  the  pylorus,  involving 
the  anterior  wall  of  the  stomach  nearly  to  the  cardiac  end.  Mid- 
way between  the  greater  and  lesser  curves  is  an  oval  perforation, 
measuring  seven  by  three  millimetres,  through  which  the  contents 
of  the  stomach  can  be  squeezed.  On  opening  the  stomachy  there  is 
a  large  ulcerated  cancer  extending  laterally  for  ten  centimetres. 
The  stomach  walls  in  the  neighborhood  of  the  ulcer  are  much  in- 
filtrated and  are  raised  and  in  places  overhang  the  ulcer.  In  the 
anterior  wall  there  is  the  perforation  already  mentioned.  The 
ulcer  does  not  extend  to  the  pyloric  ring.  The  glands  about  the 
stomach  and  pancreas  are  enlarged.  The  head  of  the  pancreas  is 
also  involved.  There  are  small  white  tumor  nodules  on  the  surface 
of  the  omentum  and  mesentery. 

Death  from  perforative  peritonitis  is  not  a  very  uncom- 
mon complication  of  cancer.  Perforation  may  also  take 
place  externally.  A  more  common  communication  is  with 
the  colon,  which  in  all  probability  took  place  in  Case 
XXIY.  A  rare  perforation  in  cancer,  which  I  do  not  see 
mentioned  even  in  the  exhaustive  article  of  Professor 
Welch,  is  into  the  pericardium,  which  I  found  at  autopsy 
in  a  case  of  the  late  Palmer  Howard's,  of  Montreal.  There 
was,  of  course,  the  most  intense  pericarditis,  and  the  group 
of  physical  signs  of  pneumopericardium. 

(c)  Massive  Tumors  of  the  Stomach. — No  cases  are 
more  difficult  to  recognize  than  those  in  which  the  walls 
of  the  stomach  are  extensively  infiltrated.  You  might 
think  that  under  these  circumstances  the  diagnosis  would 
be  made  with  the  greatest  ease,  but  in  reality  they  are 
cases  which  require  no  little  care  and  study.  Of  the  three 
cases  which  I  shall  narrate  to  you,  in  one  the  diagnosis 
was  easy  and  definite ;  in  one  the  tumor  was  so  extensive, 
occupying  such  a  large  area  in  the  left  side  of  the  abdo- 
men, that  some  doubt  existed  as  to  whether  it  was  not 
associated  with  the  spleen  or  the  kidney,  while  in  the 


58  THE  DIAGNOSIS  OP  ABDOMINAL  TUMORS. 

third  there  remains  a  doubt  as  to  the  exact  nature  of  the 
growth. 

Case  XXII.  Cancer  of  the  Stomach;  Prominent  Tumor  in 
the  Epigastric  Region. — H.  P.  C.  aged  fifty-seven  years,  admitted 
September  1, 1892,  complaining  of  loss  of  appetite,  progressive  weak- 
ness, and  irregular  pains  in  the  abdomen.  Family  history  is  good; 
parents  lived  to  old  age. 

Patient  since  childhood  has  been  healthy;  appetite  always  good 
until  about  six  years  ago,  when  he  began  to  have  dyspepsia,  occa- 
sional attacks  of  nausea  and  eructations,  and  sometimes  vomiting. 
He  appears  at  this  time  to  have  had  considerable  gastro-intestinal 
disturbance,  as  he  had  also  diarrhoea,  and  became  very  weak  and 
emaciated— quite  as  much  so,  he  says,  as  he  is  at  present— and  the 
ankles  were  also  swollen.  The  vomiting  and  nausea  and  diarrhoea 
stopped  and  he  gained  in  weight,  but  his  digestion  for  the  past  five 
years  has  not  been  as  strong  as  before  the  illness  six  years  ago.  In 
June  of  this  year  he  began  to  have  feelings  of  oppression  in  the 
stomach,  as  though  he  had  eaten  a  very  full  meal,  but  he  had  no 
vomiting;  once  or  twice  the  food  has  been  regurgitated.  A  marked 
symptom  at  first  was  inability  to  swallow  after  the  second  or  third 
mouthful.  With  these  local  symptoms  there  has  been  loss  of  appe- 
tite and  progi'essive  emaciation.  He  has  lost  forty  pounds  since 
June.  He  has  never  had  any  severe  pain ;  only  a  feeling  of  heavi- 
ness and  distention  after  eating. 

Condition  on  Admission. — Patient  is  a  large,  well  built-man; 
face  pale,  and  he  looks  depressed.  There  is  marked  emaciation. 
The  pulse  is  of  fair  volume  and  the  heart's  action  is  strong.  The 
temperature  during  the  sixteen  days  he  was  under  observation  was 
always  a  little  elevated  toward  evening,  rising  on  several  occasions 
to  102°.     He  had  no  cough ;  respirations  quiet. 

Abdomen  flat,  except  in  the  epigastric  region,  in  which  it  is  a 
little  prominent.  On  palpation,  it  is  soft,  painless,  and  just  below 
the  ensiform  cartilage,  extending  across  the  whole  upper  zone,  is  a 
firm,  resistant  mass.  Above,  it  extends  to  within  two  inches  of  the 
ensiform  cartilage,  and  the  lower  margin  was  rather  more  than 
this  distance  from  the  navel.  To  the  left  it  passed  under  the  costal 
margin  opnosite  the  seventh  and  eighth  cartilages.     To  the  right  it 


NODULAR  AND   MASSIVE  TUxMORS  OF  THE  STOMACH.    59 


reached  nearly,  but  not  quite,  to  the  costal  margin.  There  was  a 
distinct  concavity  above  and  a  convexity  below,  and  at  no  time 
was  the  mass  below  the  level  of  a  line  joining  the  tips  of  the 
eleventh  ribs.  It  was  at  times  much  more  prominent  than  at 
others.  On  palpation,  it  was  firm,  gave  an  impression  of  solidity, 
was  quite  painless,  of  uniform  resistance  in  all  parts,  and  toward 
the  left  j)assed  beneath  the  costal  margin.  To  the  right  it  ter- 
minated at  a  much  higher  position  than  is  usual  for  the  pyloric 
orifice.  No  movements  were  noticed 
in  it,  but  the  hand  placed  upon  it 
occasionally  felt  distinct  gurgling. 
Everywhere  over  it  there  was,  on  per- 
cussion, modified  resonance.  There 
were  no  nodules. 

At  no  time  during  the  patient's 
stay  in  the  hospital  was  there  vomit- 
ing, nor  could  it  be  said  there  was 
marked  distaste  for  food.  At  first  he 
took  an  ordinary  diet,  but,  finding  that 
it  gave  a  good  deal  of  distress,  it  was 
replaced  by  a  liquid  diet  of  egg  albu- 
min and  milk,  which  agreed  very  well. 
Mentally  he  was  very  despondent. 

Bismuth  and  soda  were  at  first 
given  an  hour  or  so  after  eating,  and 
they  relieved  promptly  the  sense  of  oppression.  It  was  not  thought 
worth  while  to  distress  him  with  attempts  at  lavage  or  test  break- 
fasts.   Patient  left  the  hospital  unimproved  on  the  19th. 

Patient  died  September  28,  1892. 

Case  XXIII. — Unusually  Large  Cancer  of  the  Stomach. — 
Mrs.  L.,  aged  about  fifty  years,  seen  September  12,  1892.  The 
patient  has  been  a  high-strung,  nervous  woman,  and  has  not  been 
in  her  usual  health  for  the  past  two  years,  complaining  chiefiy  of 
weakness  and  ill-defined  nervous  symptoms.  I  saw  her  a  year  ago 
for  these  symptoms,  and  at  that  time  made  an  examination  of  the 
abdomen,  which  was  negative.  In  June  she  was  seen  by  a  physi- 
cian, who  tells  me  that  there  was  a  lump  on  the  left  side  which  he 
thought  was  a  floating  kidney. 


Fig.  18.- 


Area  of  the  tumor  in  Case 
XXII. 


60  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

During  the  early  summer  she  was  under  the  care  of  a  New 
York  quack,  who  put  her  upon  meat  diet  and  hot  water,  under 
which  treatment  she  appeared  to  improve.  She  went  north  to  a 
watering  place,  and,  though  growing  weaker  and  losing  rapi-dly  in 
weight,  she  kept  up  until  August,  when,  on  account  of  the  swelling 
of  the  feet,  she  consented  to  go  to  bed.  All  this  time  she  was 
chiefly  on  the  meat  diet,  and  apparently  digested  it  very  well,  as 
she  had  no  eructations  and  no  vomiting.  Subsequently  she  had  a 
more  varied  diet  and  complained  a  good  deal  of  distention  and  un- 
easiness after  eating,  and  on  several  occasions  had  regurgitation  of 
food.  The  lump  in  the  left  side  had  apparently  increased  in  size, 
but  caused  her  very  little  pain,  except  when  it  was  rubbed  by  the 
masseuse. 

The  condition  when  I  saw  her  was  as  follows :  Profound  ema- 
ciation, particularly  marked  in  the  face.  The  mind  quite  clear; 
the  voice  strong,  and  the  grasp  of  the  hand  firm  and  good.  In 
spite  of  great  wasting,  she  did  not  look  cachectic,  and  the  color  of 
the  lips  was  good.  Pulse  84,  of  fair  volume;  temperature  normal. 
Tongue  was  red  with  a  light  furry  coat.  Her  chief  complaint  was 
of  uneasy  feelings  of  distention  after  food,  and  of  the  weakness 
and  prostration.  The  sleep  was  not,  as  a  rule,  disturbed,  though 
she  had  been  taking  opium  suppositories  to  allay  the  irregular 
pains  in  the  side.     She  had  no  cough ;  no  diarrhoea. 

The  abdomen  was  a  little  distended,  contrasting  with  the  ex- 
treme emaciation  of  the  thorax.  The  upper  zone  was  fuU  and  the 
skin  over  the  left  hypochondriac  and  umbilical  regions  reddened 
with  applications,  and  these  parts  looked  the  most  prominent.  No 
peristaltic  movements  were  noticed  on  inspection.  On  palpation, 
there  was  felt  a  large  mass  occupying  the  area  shown  in  the  an- 
nexed diagram,  extending  to  the  right  2*5  centimetres  beyond  the 
navel  and  the  same  distance  below.  The  edge  passed  transversely 
to  the  left  to  a  point  four  centimetres  above  the  anterior  superior 
spine;  the  edge  could  then  be  followed  readily  in  the  line  of  this 
spine  to  the  point  of  the  last  rib.  Above,  it  passed  beneath  the 
costal  margin,  and  the  upper  line  reached  to  within  five  centi- 
metres of  the  ensiform  cartilage.  It  felt  superficial,  firm,  not  ten- 
der ;  below  and  to  the  right  the  edge  was  unusually  distinct,  and 
just  at  the  navel  there  was  a  slight  depression.     The  hinder  edge 


NODULAR  AND   MASSIVE  TUMORS  OF  THE  STOMACH.    61 


could  be  distinctly  felt,  and  it  did  not  pass  deep  into  the  renal 
region. 

On  bimanual  palpation,  the  mass  could  be  moved  slightly.  At 
the  first  examination  there  was  no  gurgling  to  be  felt.  On  percus- 
sion, it  was  flat  in  the  greater  portion  of  its  extent,  but  in  the 
right  fourth  of  the  mass  it  was  distinctly  resonant. 

There  were  no  glandular  enlargements.  The  blood  examina- 
tion was  negative,  with  the  exception  of  a  very  great  increase  in 
the  blood  plates. 

I  was  not  a  little  puzzled  at  first  as  to  the  nature  of  this  tumor. 
The  situation,  the  flatness,  its  superficial  character,  excluded 
definitely,  it  seemed,  a  movable  kid- 
ney, which  would  not  for  a  moment 
have  been  considered  had  I  not  been 
informed  that  a  physician  in  whose 
judgment  I  have  great  confidence 
had  in  June  pronounced  this  to  be 
the  condition  present.  The  situation 
was  suggestive,  naturally,  of  an  en- 
larged spleen  ;  the  right  edge  seemed 
thin  and  there  was  an  indistinct  feel- 
ing of  a  notch,  but  the  very  super- 
ficial character,  the  absence  of  a  defi- 
nite notch  or  notches,  and,  above  all, 
the  resonance  over  one  half  of  the 
tumor,  seemed  inconsistent  with  this 
view.  A  phantom  tumor  in  a  hys- 
terical woman  had  also  been  suggest- 
ed. The  large  size,  the  unusual  situ- 
ation, and  the  slight  character  o  fthe 

gastric  symptoms  did  not  favor  gastric  carcinoma,  suggested,  of 
course,  by  the  profound  emaciation  and  the  existence  of  resonant 
tumor  in  the  left  hypochondrium. 

The  next  few  days,  however,  developed  additional  symptoms 
which  made  this  view  very  much  more  likely.  On  the  12th  she 
had  taken  six  oysters  and  one  on  the  13th.  On  the  15th  she  had 
eructations  of  dark,  very  offensive  material,  and  regurgitated  one 
of  the  oysters  in  a  condition  of  decomposition,  but  undigested.     On 


Fig.  19.- The  tumor  area  in  Case 
XXIII. 


62  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

the  16th  she  regurgitated  the  chopped  meat  in  a  similar  condition 
of  decomposition,  and  a  second  oyster  which  had  been  very  slightly 
acted  upon.  The  odor  of  the  materials  brought  up  was  intensely 
oflFensive.  She  had  also  at  this  time  slight  diarrhoea.  The  tumor 
did  not  show  any  mateinal  changes,  but  the  area  of  resonance 
seemed  to  vary  somewhat,  and,  on  drinking,  gurgling  could  be 
distinctly  heard  over  the  mass,  and  sometimes  with  the  hand  upon 
the  tumor  the  flatus  could  be  felt. 

September  19th. — For  the  first  time  the  patient  to-day  had 
attacks  of  actual  vomiting,  the  first  at  about  six  in  the  morning 
and  the  second  at  noon.  On  both  occasions  she  brought  up  about 
half  a  pint  of  dark,  bloody  fluid  of  a  most  horribly  offensive  char- 
acter, having  a  distinctly  faecal  odor,  as  well  as  an  odor  of  decom- 
position. In  the  material  last  vomited  there  were  several  grayish, 
sloughy  masses  the  size  of  peas,  which  under  the  microscope  did 
not  show  any  definite  structure.  The  patient  after  these  attacks 
was  much  exhausted. 

For  a  week  after  this  there  was  vomiting  and  at  intervals  entire 
inability  to  take  food,  and  occasionally  vomiting  of  the  same  offen- 
sive material. 

Died  gradually  of  asthenia.    There  was  no  autopsy. 

The  extent  of  tlie  tumor  was  due  to  infiltration  of  a 
very  large  area  of  the  anterior  wall  and  fundus  of  the 
organ.  In  all  probability  there  was  also  extension  to  the 
omentum  and  to  the  colon.  Evidently  sloughing  took 
place  in  the  tumor  mass,  and,  judging  from  the  fsecal 
odor  of  the  vomitus,  perforation  into  the  colon  had  oc- 
curred. 

Case  XXIV.  Large,  Massive  Tumor  in  the  Epigastric  and 
Upper  Umbilical  Regions. — Patrick  C,  harness  maker,  aged  fifty- 
six  years,  admitted  April  15th,  complaining  of  weakness  and  a 
lump  in  the  left  side. 

Family  history  is  negative  ;  father  died  of  accident ;  mother, 
cause  unknown,  aged  fifty-five  years. 

Patient  has  never  been  a  very  strong  man  ;  was  hurt  when  a 
lad  by  falling  off  a  load  of  hay  ;  rheumatism  in  1876.     Has  always 


NODULAR  AND  MASSIVE  TUMORS  OF  THE  STOMACH.    63 

been  rather  pale  ;  lived  a  sedentary  life  ;  has  not  been  a  heavy 
drinker  ;  never  had  venereal  disease.  Within  the  past  year  he  has 
lost  between  twenty  and  thirty  pounds  in  weight. 

Present  illness  began  about  a  year  ago  with  diarrhoea,  which 
persisted  for  between  eight  and  nine  months.  Sometimes  he 
would  have  four  or  five  stools  in  an  hour,  and  often  as  many  as 
twenty  in  a  day.  Never  passed  any  blood  ;  sometimes  would  have 
none  for  two  days.  Was  always  better  when  he  rested  in  bed. 
Thirteen  weeks  ago  he  left  off  work  on  account  of  the  weakness, 
and  during  this  time  he  has  been  rather  inclined  to  constipation. 
He  thinks  he  has  become  paler.  One  day  about  three  months  ago 
he  felt  a  lump  under  the  left  ribs,  and  this  he  thinks  has  increased 
in  size.  His  appetite  has  been  variable  ;  lately  it  has  improved 
somewhat.  He  has  had  no  nausea  and  no  vomiting  ;  no  trouble  in 
digesting  his  food.  Once  or  twice  has  had  slight  nausea  after 
taking  milk.  Has  had  no  pain  ;  only  a  slight  heavy  feeling  in 
the  left  side. 

Present  Condition. — Patient  is  pale,  but  not  specially  emaci- 
ated ;  hair  and  beard  gray  ;  conjunctivae  pearly  white.  Tongue 
lightly  furred.     Pulse,  96  ;  vessel  wall  not  sclerosed. 

Abdomen  a  little  prominent  to  left  of  navel  ;  throbbing  of 
abdominal  aorta  marked.  Subcutaneous  veins  not  enlarged.  On 
palpation,  occupying  the  left  hypochondriac,  the  left  half  of  the 
epigastric,  and  the  upper  and  left  part  of  the  umbilical  regions, 
is  a  large  flat  mass.  To  the  right  it  extends  a  little  beyond  the 
navel,  and  here  the  edge  can  be  felt,  and  at  the  lower  part  the 
suspicion  of  a  notch.  The  upper  limit  is  ill-defined.  At  the  cos- 
tal margin  it  is  felt  to  extend  a  short  distance  under  the  ribs.  On 
deep  inspiration  the  hand  can  be  placed  between  the  costal  bor- 
der and  the  tumor,  which  in  this  region  has  a  distinctly  rounded 
globular  surface.  Above  and  to  the  right  it  can  be  separated 
distinctly  from  the  liver.  During  inspiration  and  on  deep  pal- 
pation no  splenic  margin  can  be  detected  in  the  normal  position. 
On  prolonged  palpation  of  the  tumor,  no  changes  in  consistence 
can  be  felt  ;  no  gas  is  noticed  to  bubble  through  it. 

Percussion. — In  the  middle  line  there  is  no  dullness.  There  is 
resonance  over  the  whole  tumor.  A  modified,  flat  tympany  is 
elicited  in  the  left  half  of  the  epigastric  region.     The  stomach 


04: 


THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 


tympany  begins  in  the  parasternal  line  at  the  upper  margin  of  the 
seventh,  and  extends  to  two  fingers'  breadth  above  the  navel.  The 
artificial  inflation  of  the  stomach  did  not  show  any  marked 
changes,  and  no  gas  was  felt  bubbling  in  the  mass.  The  disten- 
tion of  colon  with  air  made  no  change  in  it. 

The  mass  is  distinctly,  though  not  very  freely,  movable.     It  can 
not  be  pushed  back  under  the  costal  margin,  and  in  fact  can  not 

be  moved  to  the  left  so  that  its  right 
margin  is  beyond  the  middle  line.  It 
does  not  extend  deep  into  the  renal 
region,  palpation  in  which  is  normal. 
The  tumor  mass  is  not  at  all  sensi- 
tive. The  liver  dullness  is  reduced  ; 
in  the  nipple  line  not  more  than  a 
finger's  breadth  ;  in  the  axillary  line 
no  actual  dullness.  Though  there  is 
this  extreme  diminution  in  the  area 
of  liver  dullness,  the  edge 'of  the  or- 
gan can  be  distinctly  felt  just  below 
the  costal  margin.  Although  the 
edge  of  the  spleen  could  not  be  felt 
under  the  left  costal  margin,  there 
was  at  the  first  examination  definite 
splenic  dullness  over  the  ninth  and 
tenth  ribs  in  the  mid-axillary  line. 
The  blood  condition  shows  a  profound  secondary  aneemia,  and  is 
not  specially  suggestive  of  a  splenic  form.  The  examination  shows 
only  thirty  per  cent,  of  haemoglobin,  a  little  over  three  million  red 
blood-corpuscles  to  the  cubic  millimetre,  and  a  little  over  nine 
thousand  white  corpuscles. 

The  urine  is  negative,  pale,  no  abnormal  deposits,  no  casts. 
He  is  constipated.  Stools  formed,  and  presented  no  special  fea- 
tures. 

A  test  breakfast  showed  no  free  hydrochloric  acid. 

Comments. — April  19,  1893.     It  has  been  suggested   that  this 

mass  might  possibly  be  a  dislocated  and   fixed   spleen,  but  the 

solidity  and  firmness,   the   rounded   character  of   the   mass,   and 

the   indefiniteness    of    the  notches   (supposed    to    be    felt),   were 


Fig.  20.— Outline  of  the  tumor  in 
Case  XXIV. 


I 


MODULAR  AND  MASSIVE  TUMORS  OF  THE  STOMACH.    65 

against  this.  Moreover,  dislocated  enlarged  spleens  are  usually 
very  mobile,  and,  most  important  of  all,  the  splenic  dullness  was 
quite  marked  in  the  mid-axillary  line,  and  the  mass  was  every- 
where resonant. 

One  of  the  most  suggestive  features  of  the  case  is  the  onset  of 
the  disease  with  diarrhoea.  The  situation  of  the  mass,  its  fixity, 
and  its  size  are  against  tumor  of  the  colon.  There  are,  on  the 
other  hand,  instances  of  malignant  disease  of  the  small  bowel  in 
which  the  tumor  mass  has  attained  a  very  large  size,  and  in  which 
progressive  emaciation,  anaemia,  and  diarrhoea  have  been  the  main 
symptoms.  The  most  remarkable  case  of  this  which  I  call  to  mind 
is  one  which  I  saw  at  the  General  Hospital,  Montreal,  with  Dr. 
Molson,  for  whom  I  made  the  dissection.  A  man,  aged  forty-one 
years,  was  admitted  on  March  4,  1882,  with  swelling  of  the  feet, 
vomiting,  and  constipation.  For  six  months  he  had  had  pains  and 
vomiting  and  more  or  less  constipation,  with  loss  of  flesh.  The 
patient  had  general  anasarca  and  shortness  of  breath.  The  ab- 
domen was  full  and  large,  and  the  examination  was  very  diflBcult 
on  account  of  the  infiltration  of  the  abdominal  walls,  and  there 
was  ascites. 

The  post-mortem  showed  a  large  mass  occupying  the  left  half 
of  the  abdomen,  from  the  ribs  to  the  crest  of  the  ilium.  It  was 
firmly  attached  to  the  left  kidney  behind,  and  the  colon  and  sig- 
moid flexure  were  at  its  left  border.  It  was  removed  wath  the 
small  intestine,  and  the  tumor  was  found  to  involve  eighteen 
inches  of  the  jejunum,  which  tunneled  the  mass  in  a  curved  direc- 
tion. The  walls  were  in  places  from  six  to  eight  inches  in  thick- 
ness. The  lumen  was  expanded,  the  mucosa  still  evident,  present- 
ing blunt  valvulae  conniventes. 

In  Case  XXIV  the  main  portion  of  this  tumor  is  in  the  epigas- 
tric region  in  the  situation  of  the  stomach.  Though  firm  and 
solid,  it  was  resonant,  and,  in  the  absence  of  definite  features,  the 
probabilities  seemed  to  me  that  it  was  a  large,  massive  tumor  of  the 
anterior  wall  and  fundus.  He  died  in  October,  with  what  symp- 
toms we  cotdd  not  learn.    There  was  no  autopsy. 

Finally,  let  me  sum  up  a  few  leading  points  for  your 
guidance,  based  on  the  study  of  the  cases  we  have  had 
under  consideration : 


QQ  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

1.  Though  only  a  small  section  of  stomach  is  available 
for  palpation,  a  very  large  proportion  of  all  tumors  of  the 
organ  may  be  felt,  owing  in  part  to  their  greater  frequency 
at  the  pyloric  portion,  and  in  part  owing  to  the  frequent 
depression  of  the  organ.  In  every  one  of  the  twenty-four 
cases  a  tumor  or  induration  was  detected,  and  it  is  inter- 
esting to  note  that  in  the  same  period  of  time  during 
which  these  cases  were  observed  no  instance  came  to 
autopsy  with  a  tumor  at  the  cardia  or  posterior  wall. 

2.  In  a  considerable  number  of  cases  the  dilated  stom- 
ach itself  forms  a  tumor  in  the  abdomen,  characterized 
by  undulatory  peristalsis,  sometimes  by  a  definite  stomach 
contour.  In  ten  cases  of  the  series  these  features  were 
distinct  enough  to  render  the  diagnosis  clear  on  inspection 
alone. 

3.  In  a  majority  of  cases  no  serious  trouble  is  experi- 
enced in  determining  whether  or  not  a  tumor  is  in  the 
stomach.  Excessive  mobility  of  a  pyloric  growth  and 
extensive  infiltrating  masses  in  the  epigastric  region  were 
the  only  conditions  causing  trouble  in  any  of  the  cases  of 
this  series.  The  more  systematic  and  thorough  the  ex- 
amination, the  less  is  the  liability  to  error. 

4.  The  character  of  the  tumor  is  rarely  in  doubt. 
Large,  nodular,  and  massive  growths  are  invariably  can- 
cerous. At  the  pylorus  it  may  be  difficult  to  distinguish 
between  cicatricial  thickening  about  an  ulcer,  hypertrophic 
stenosis,  and  annular  scirrhus.  It  may,  in  fact,  be  impos- 
sible to  decide  the  question.  The  age,  previous  history, 
the  general  and  local  conditions — all  have  to  be  carefully 
taken  into  account,  but,  as  in  cases  XIII,  XIV,  and  XV, 
it  may  not  be  possible  to  reach  a  definite  conclusion. 

And,  lastly,  the  very  serious  nature  of  tumors  of  the 
stomach  may  be  gathered  from  the  fact  that,  of  the 
twenty-four  patients,  eight  have  already  died. 


LECTURE  III. 

TUMORS   OF   THE   LIVER. 

Let  me  remind  you  of  two  anatomical^  points :  First, 
that  the  liver  extends  entirely  across  the  upper  portion  of 
the  abdominal  cavity,  so  that  tumors  may  project  to  either 
side  of  the  middle  line  in  front,  more  rarely  into  the  left 
pleura  behind ;  and  secondly,  that  in  women  the  organ  is 
frequently  so  dislocated  that  a  large  part  of  the  convexity 
is  in  contact  with  the  anterior  abdominal  wall ;  moreover, 
the  anterior  margin  may  be  irregular  from  the  projection 
of  tongue-like  portions,  to  which  special  attention  will  be 
directed  in  cont^idering  tumors  of  the  gall-bladder. 

Tumors  of  the  liver  are  common,  and,  as  a  rule,  their 
nature  is  not  difficult  to  recognize.  I  shall  not  here  refer 
to  the  simple  enlargements  of  the  organ  in  hypertrophic 
cirrhosis,  in  amyloid  and  fatty  degenerations,  or  to  the 
cases  of  uniform  increase  in  volume  met  with  in  cancer 
and  abscess.  I  shall  call  your  attention  only  to  those  in 
which  a  prominent  nodular  mass  or  swelling — a  tumor — 
was  detected,  and  the  nature  of  which  had  to  be  decided. 

The  usual  causes  are  cancer,  abscess,  syphilis,  hydatids, 
and  occasionally  tuberculosis.  The  tumors  in  connection 
with  the  gall-bladder  I  shall  consider  separately.  Under 
certain  circumstances  the  liver  itself  may  form  a  tumor- 
like structure.  The  cases  which  have  come  before  me  for 
diagnosis  in  the  past  twelve  months  are  distributed  as  fol- 
lows :   The  liver  itself,  one ;  abscess,  four ;  syphilis,  two ; 

cancer,  four. 

8  67 


68 


THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 


I.  Tumor  formed  by  the  Liver  itself. — I  show 
you  here  a  little  patient  (Case  XXV)  in  the  upper  part 
of  whose  abdomen  you  can  see,  even  from  a  distance,  a 
prominent    tumor,  which  pulsates   actively   at  the  rate 


of  ninety  per  minute,  lifting  the  skin  in  the  epigastric 
region.  This  case  has  been  under  our  care  on  and  off  for 
the  past  two  years.  She  is  thirteen  years  of  age,  and  has 
an  old  mitral-valve  lesion  from  rheumatism,  with  enor- 


TUMORS  OP  THE  LIVER.  69 

mous  enlargement  of  the  heart.  The  apex  beat  is,  as  you 
see,  far  out  in  the  sixth  and  seventh  interspaces.  The 
prsecordia  is  very  prominent,  and  there  are  signs  indicat- 
ing that  the  pericardium  is  adherent.  During  the  past 
eighteen  months  ascites  has  constantly  recurred,  so  that 
she  is  now  tapped  once  a  week,  yesterday  for  the  seventy- 
first  time.  When  the  abdomen  is  distended  nothing  is 
noticed,  but  after  the  fluid  is  withdrawn  this  remarkable 
tumor-like  mass  appears  in  the  epigastrium  (Fig.  21).  On 
palpation  it  is  smooth,  with  a  rounded  edge,  descends  with 
inspiration,  and  expands  visibly;  and  under  the  fingers, 
during  the  cardiac  systole,  it  can  be  traced  to  the  right, 
where  at  about  the  nipple  line  it  passes  beneath  the  costal 
margin.  As  it  pulsates  there  can  be  felt,  particularly  at 
these  periods,  a  to-and-fro  peritoneal  friction  rub.  The 
pulsation  is  expansile,  and  with  the  fingers  of  the  left  hand 
beneath  the  costal  margin  in  the  nipple  line,  and  the  right 
hand  over  the  prominent  mass,  the  whole  structure  can  be 
felt  to  expand  with  each  contraction  of  the  heart.  The 
situation,  tlie  shape,  and  the  character  of  the  pulsation 
leave  no  doubt  whatever  that  this  is  a  pulsating  liver,  a 
not  very  uncommon  condition  in  chronic  mitral  disease, 
when  the  tricuspid  becomes  insufficient  and  allows  each 
systole  of  the  right  ventricle  to  be  communicated  through 
the  right  auricle  directly  to  the  column  of  blood  in  the 
hepatic  veins.  The  deformity  of  the  liver,  its  cakelike 
shape,  and  rounded  edge  are  caused,  I  believe,  by  a  peri- 
hepatitis, possibly  a  direct  extension  from  the  pericar- 
dium, associated  with  which  there  is  a  chronic  prolifer- 
ative peritonitis.  The  recurring  ascites  is  due  partly  to  the 
contraction  of  the  liver  by  the  perihepatitis,  partly  to  the 
chronic  peritonitis.  A  case  with  almost  identical  features 
was  for  a  long  time  under  my  observation  at  the  Univer- 
sity Hospital,  Philadelphia. 

In  two   other  conditions — neither  of  which,  however. 


70  THE  DIAGNOSIS  OP  ABDOMINAL  TUMORS. 

has  "been  before  us  this  year — the  liver  itself  may  form  a 
tumor  and  cause  no  little  difficulty  in  diagnosis :  first,  the 
so-called  floating  liver,  which  is  most  commonly  met  with 
in  women  (though  sometimes  met  with  in  men,  as  in  a 
recent  case  reported  by  Kreider,  of  Springfield,  111.),  and 
is  a  feature  of  enteroptosis ;  and  second,  the  cases  of  great 
shrinkage  and  deformity  of  the  liver  in  syphilis,  in  which 
the  whole  organ  may  be  converted  into  a  cluster  of  irregu- 
lar nodular  masses,  held  together  by  fibrous  tissue,  a  con- 
dition to  which  the  term  hotryoid  has  been  given  from  its 
resemblance  to  a  bunch  of  grapes. 

II.  Abscess  of  the  Liver. — Unfortunately  for  the 
victims  of  this  serious  disease,  a  prominent  tumor  mass  is 
only  occasionally  present.  Of  nine  cases  of  abscess  of  the 
liver  seen  since  the  first  of  September  of  last  year,  of 
which  seven  were  in  the  hospital  (hospital  numbers  5876, 
6109,  6745,  7679,  7687,  7738,  and  8001),  four  presented  a 
prominent  tumor,  the  nature  of  which  came  up  for  dis- 
cussion. 

Case  XXVI.  Abscess  of  the  Liver;  Prominent  Tumor;  In- 
cision; Recovery. — Dr.  X.,  aged  sixty  years,  admitted  September 
6,  1892,  complaining'  of  weakness  and  of  a  painful  tumor  in  the 
side.  Family  history  good.  The  patient  has  been  a  healthy  man 
and  has  had  very  few  illnesses,  the  only  severe  one  being  typhoid 
fever,  in  1863.  The  present  trouble  dates  from  April  of  this  year? 
when  he  began  to  have  pain  in  the  right  side,  fever,  and  chilly  sen- 
sations. The  temperature  sometimes  rose  to  103°,  and  he  had  a 
sense  of  distention  and  fullness  in  the  right  side,  but  there  was  no 
bulging,  as  at  present.  No  history  can  be  obtained  of  any  local 
disease  in  the  gastro-intestinal  tract.  He  is  positive  that  there  had 
been  no  diarrhoea.  After  a  month,  during  the  greater  part  of 
which  time  he  was  in  bed,  the  fever  disappeared,  but  the  pain  and 
fullness  in  the  right  side  persisted.  Toward  the  end  of  June  he 
noticed  that  there  was  a  prominence  below  the  right  costal  margin 
which  has  steadily  increased.  He  has  lost  much  in  weight — from 
250  to  185  pounds.    Since  June  he  has  had  at  times  slight  fever,  but 


TUMOES  OF  THE  LIVER. 


■71 


no  chills,  and  only  occasional  sweating.  The  bowels  have  been 
irregular,  and  he  has  had  to  take  purgatives.  There  has  never  at 
any  time  been  jaundice. 

Present  Condition. — Fairly  well  nourished,  a  little  pale,  but 


neither  emaciated  nor  cachectic.  Temperature  last  evening  101° ; 
pulse  104,  occasionally  intermits.  The  radials  are  sclerotic.  The 
tongue  is  red,  not  dry. 

Abdomen. — A  large  tumor  mass  fills  up  the  right  half,  and  is 
strikingly  prominent,  as  indicated  in  the  figure  from  a  photograph 


72  THE  DIAGNOSIS  OP  ABDOMINAL  TUMORS. 

(Fig.  22).  Below,  it  reaches  the  transverse  umbilical  line ;  above, 
it  passes  beneath  the  costal  margin.  To  the  left  the  swelling  be- 
gins at  the  middle  line.  The  skin  over  it  is  glossy  and  a  little  red- 
dened. The  respiratory  movements  of  the  abdomen  are  slight.  On 
palpation,  the  entire  right  side  above  the  transverse  iliac  line  is 
occupied  by  a  solid  mass  which  is  resistant  except  at  the  most 
prominent  point,  where  it  is  soft  and  fluctuating.  It  is  nowhere 
painful  on  pressure.  Below,  no  definite  sharp  edge  can  be  felt. 
Above,  it  is  continuous  with  and  not  to  be  separated  from  the  liver. 
Behind,  it  occupies  the  entire  flank  and  can  be  felt  on  deep  pressure 
below  the  eleventh  rib.  On  bimanual  palpation  it  is  fixed,  not 
mobile.  Percussion  gives  a  flat  note  everywhere  over  the  tumor. 
Liver  dullness  begins  at  the  seventh  rib  and  is  continuous  with 
that  of  the  tumor  mass.  In  the  parasternal  line  there  is  a  slight 
resonance  between  the  margin  of  the  ribs  and  the  tumor.  The 
spleen  is  not  palpable;  area  of  dullness  not  increased. 

The  cervical  and  inguinal  glands  are  not  enlarged.  There  is  a 
soft  systolic  murmur  at  the  apex ;  otherwise  the  examination  of  the 
thoracic  organs  is  negative. 

As  doubt  had  been  expressed  by  several  physicians  who  had 
examined  Dr.  X.  as  to  the  nature  of  the  tumor,  an  exploratory 
aspiration  was  made  in  the  most  prominent  portion  and  a  grayish- 
red  pus  withdrawn,  which  on  examination  contained  much  molec- 
ular debris,  pus  cells,  fatty  crystals,  but  no  amoebae. 

On  the  10th,  under  chloroform.  Dr.  Finney  made  an  oblique  in- 
cision over  the  tumor  and  opened  a  large  abscess  cavity  in  the  liver, 
removing  more  than  a  litre  of  foul-smelling  pus,  darkish  in  color  ; 
on  examination,  no  amcebae  were  found.  The  walls  of  the  abscess 
cavity,  as  felt  by  the  finger,  extended  beyond  the  middle  line  and  up- 
ward out  of  reach  beneath  the  ribs.  They  were  everywhere  hard 
and  firm.  The  patient  reacted  well  after  the  operation  ;  the  tem- 
perature fell,  and  on  the  sixth  day  he  was  wheeling  himself  about 
the  ward  in  a  chair. 

Patient  left  the  hospital  September  28th,  and  when  last  heard 
from,  six  months  after  the  operation,  remained  well. 

Case  XXVII.  Abscess  of  the  Liver;  Prominent  Tumor  in  the 
Epigastrium. — Mr.  W.,  merchant,  aged  fifty-four  years,  seen  Sep- 
tember 16,  1893,  with  Dr.  Opie.    Patient  was  a  healthy  man  until 


TUMORS  OP  THE  LIVER.  73 

July,  1892.  Has  had  the  ordinary  diseases,  and  syphilis  when  a 
young  man.  Twenty  or  more  years  ago  he  had  diarrhoea  for  some 
time. 

He  dates  his  present  illness  from  July,  1892,  when  without  any 
vomiting  or  diarrhoea  he  began  to  have  pains  in  the  abdomen,  which 
persisted  with  great  severity  for  about  two  weeks.  At  this  time  he 
could  not  straighten  himself  without  very  great  pain.  The  abdo- 
men was  swollen ;  he  had  no  jaundice.  He  improved  somewhat  and 
went  away  for  about  six  weeks  and  gained  a  great  deal  in  weight. 
In  September,  on  his  return,  he  again  had  the  severe  pain  and  op- 
pression in  breathing.  He  was  at  this  time  under  the  care  of  Dr. 
Opie  and  Dr.  Chambers,  who  state  that  the  liver  was  greatly  en- 
larged. Abscess  was  suspected,  and  an  operation  was  suggested  but 
declined.  The  swelling  was  not  so  marked  as  it  is  at  present.  He 
does  not  appear  to  have  had  any  chills,  sweats,  or  indeed  much  fever. 
There  never  has  been  jaundice,  and  it  was  subsequently  suggested 
that  the  enlargement  of  the  liver  was  due  to  syphilitic  disease.  He 
lost  a  great  deal  of  flesh  during  this  illness — as  much,  he  thinks,  as 
fifty  pounds.  Throughout  the  early  part  of  this  year  he  was  very 
much  better  and  gained  about  twenty-five  pounds  in  weight.  He 
went  away  in  March,  but  was  not  at  all  benefited  by  the  change.  He 
lost  strength  and  flesh,  and  lately  has  had  a  great  deal  of  dragging 
pain  in  the  side,  particularly  if  he  attempts  to  lie  on  the  left  side. 
He  has  had  no  diarrhoea  and  no  vomiting. 

The  patient  is  a  large-framed  man,  with  sallow  complexion, 
looks  ill,  and  is  decidedly  emaciated.  He  was  sitting  up  ;  no  swell- 
ing of  the  feet  ;  conjunctivae  pale  but  not  jaundiced.  The  pulse  is 
9G,  tension  not  increased  ;  he  has  no  fever. 

The  abdomen  is  enlarged  and  a  prominent  tumor  fills  the  epigas- 
tric region  and  extends  toward  the  left  hypochondrium.  The  skin 
over  it  is  glistening,  dry,  and  abraded  from  counter-irritation.  The 
superficial  veins  are  not  specially  enlarged,  except  the  left  mam- 
mary, which  is  prominent.  No  enlargement  of  the  superficial 
glands.  On  palpation,  the  abdomen  is  soft  and  natural  until  just  at 
the  level  of  the  navel.  Here  the  edge  of  the  liver  can  be  distinctly 
felt.  To  the  left  the  edge  passes  obliquely  and  can  be  felt  to  pass 
under  the  costal  margin  at  the  ninth  cartilage.  To  the  right  the 
edge  passes  obliquely  upward  and  can  be  felt  at  the  costal  margin  at 


74: 


THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 


about  the  tenth  rib.  Occupying  the  right  epigastric  region  there  is  a 
prominent  flat  projection  which  causes  a  distinct  asymmetry  in  this 
region.  It  is  not  painful  on  pressure.  It  is  soft  and  boggy,  but 
there  is  no  definite  fluctuation.  Percussion  shows  the  liver  dullness 
to  be  greatly  increased.  Above,  it  extends  nearly  to  the  lower  mar- 
gin of  the  fourth  rib,  crosses  the  sternum  opposite  the  cartilage  of  the 
fifth  rib,  and  is  continuous  with  the  cardiac  dullness.  There  is  a  ver- 
tical liver  dullness  from  the  fourth  interspace  to  the  level  of  the 
navel  in  the  parasternal  line.  Behind,  the  dullness  reaches  very 
high,  almost  to  the  angle  of  the  scapula. 

The  spleen  is  not  enlarged.  The  heart  is  a  little  pushed  up  ;  the 
sounds  are  clear.     The  examination  of  the  lungs  is  negative. 

The  diagnosis  of  the  condition  was 
not  at  all  easy.  The  progressive 
emaciation  and  the  enormously  en- 
larged liver  and  somewhat  irregular 
outline  suggested,  of  course,  cancer, 
against  which,  however,  was  the  not- 
able fact  that  he  had  improved  so 
much  after  a  very  severe  attack  last 
year,  in  which  the  liver  was  enlarged. 
The  prominent  hemispherical  mass  ia 
the  right  epigastric  region  was  sugges- 
tive of  abscess.  Though  he  had  had 
no  chills  and  no  fever,  and  although 
in  the  history  not  one  of  the  usual 
aetiological  factors  preceding  abscess 
of  the  liver  was  present,  the  sallow 
cachexia,  the  dragging  pains  on  at- 
tempting to  lie  on  the  left  side,  and 
the  prominent  doughy  tumor  of  the  liver,  made  an  exploratory  ex- 
amination advisable.  An  aspirator  needle  was  thrust  deeply  into 
the  most  prominent  part  of  the  tumor  and  immediately  a  grayish 
and  subsequently  a  reddish-brown  pus  flowed  out  freely. 

The  patient  was  removed  to  the  City  Hospital,  where  on  Septem- 
ber 21st  Dr.  Chambers  opened  the  abscess  and  removed  a  gallon 
and  a  half  of  reddish,  thin  pus,  which  microscopically  was  made  up 
of  a  granular  debris,  very  few  pus  cells  retaining  their  contour  ;  no 


Fig.  23.— Outline  of  the  liver  and 
situation  of  the  tumor  in  Case 
XXVII. 


TUMORS  OF  THE  LIVER.  'fS 

amoebae.     The  patient  rallied  from  the  operation,  but  sank  and  died 
in  about  ten  days. 

Case  XXVIII.  Abscess  of  the  Liver ;  Tumor  in  the  Right  Epi- 
gastric Region;  Rupture  into  the  Lung. — Simon  G.,  aged  twenty- 
seven  years,  admitted  July  11,  1893,  complaining  of  hiccough  and 
pain  below  the  ribs  on  the  right  side.  He  has  always  been  healthy 
until  five  years  ago,  when  he  was  laid  up  in  the  Hebrew  Hospital 
for  six  weeks  with  a  severe  cough.  His  habits  are  good  and  he  has 
not  had  venereal  disease. 

Three  weeks  ago  his  present  illness  began  with  irregular  cramps 
in  the  hepatic  region.  He  had  hiccough  for  nearly  a  week,  day  and 
night,  and  this  was  in  reality  his  most  distressing  symptom.  He 
has  vomited  several  times  ;  lost  his  appetite  and  has  only  been  able 
to  take  milk  and  whisky.  The  bowels  have  been  constipated  and  he 
had  never  had  any  severe  diarrhoea.  No  cough  ;  no  expectoration. 
On  July  1st  he  had  a  very  severe  chill  in  which  he  shook  for  an  hour, 
followed  by  fever  and  sweating.  The  following  day,  July  2d,  he 
felt  better.  On  the  3d  he  had  a  second  chill  at  eight  o'clock  in  the 
morning,  and  shook  for  an  hour.  On  the  4th  he  had  another  chill. 
He  then  went  into  the  Norfolk  Hospital,  where  he  was  given  a  great 
deal  of  quinine.  He  has  sweated  a  good  deal ;  has  not  noticed  that 
he  has  become  at  all  yellow.  He  has  lost  somewhat  in  weight. 
At  present  he  complains  of  the  incessant  hiccough  and  of  pain  in 
the  region  of  the  liver. 

Present  Condition.— Fsitient  is  fairly  well  nourished;  face  a 
little  emaciated  ;  conjunctivae  slightly  tinged.  The  skin  is  not 
jaundiced.  Tongue  has  a  light  white  fur.  Temperature  has  not 
been  above  99  "5°  since  his  admission  ;  piilse,  84  ;  tension  normal. 

On  inspection,  the  thorax  on  the  right  side  looks  a  little  fuller 
than  the  left,  particularly  bel  ind  in  the  infrascapular  region.  The 
left  intercostal  grooves  are  faintly  visible  ;  the  right  not  at  all. 
The  apex  beat  of  the  heart  is  not  visible ;  the  percussion  is  clear  on 
the  left  side;  on  the  right  fide  in  front  it  is  clear  to  the  upper 
border  of  the  sixth  in  the  nipple  line,  and  to  the  upper  border  of  the 
fifth  in  the  midaxillary  line.  Behind  there  is  defective  resonance 
at  the  angle  of  the  scapula,  shading  quickly  into  dullness.  The 
respiratory  murmur  is  heard  well  on  both  sides.  It  is  feeble  in  the 
infrascapular  region  on  the  right  side;  no  rales;  no  friction.     The 


76 


THE  DIAGNOSIS   OF  ABDOMINAL  TUMORS. 


abdomen  looks  natural,  but  there  is  a  marked  fullness  on  the  right 
side  in  the  hypochondriac  region,  and  the  groove  below  the  costal 
margin  is  completely  obliterated.  In  this  region,  occupying  a  space 
thirteen  centimetres  in  diameter,  there  is  a  very  definite  promi- 
nence. On  palpation,  this  is  resistant  and  tender,  and  the  skin  at  the 
costal  edge  seems  a  little  infiltrated.  The  liver  margin  can  be  felt 
reaching  nearly  to  the  level  of  the  navel  and  the  edge  is  rounded. 
To  the  right  it  passes  under  the  costal  margin  at  the  tip  of  the  tenth 
rib.  The  left  lobe  can  be  felt  filling  the  upper  epigastric  region. 
The  liver  dullness  extends  high  in  the  axillary  region,  reaches  the 
upper  border  of  the  fifth,  and  there  is  here  eighteen  centimetres  of 
vertical  dullness. 

The  edge  of  the  spleen  is  distinctly  palpable.  The  superficial 
lymph  glands  are  not  enlarged  and  the  examination  of  the  stom- 
ach and  intestines  is  negative.     A  rectal  tube  was  passed,  but  no 

amoebae  were  found  in  the  mucus  ob- 
tained. The  blood  examination  was 
negative. 

I  aspirated  in  the  parasternal  line 
at  the  most  prominent  point  of  the  tu- 
mor, but  obtained  no  pus. 

I  did  not  see  this  patient  again, 
but  abstract  the  following  from  Dr. 
Thayer's  notes  :  Although  no  pus  was 
obtained  on  the  first  aspiration,  there 
seemed  to  be  no  question  as  to  the  cor- 
rectness of  the  diagnosis.  Chills  oc- 
curred on  July  14th,  17th,  19th,  and 
23d,  and  on  August  1st,  3d,  and  4th. 
The  patient  was  urged  to  have  an 
operation,  but  declined.  The  tumor 
mass  remained  prominent,  but  no 
definite  fluctuation  developed.  On 
August  20th  the  patient  suddenly 
began  to  cough,  calling  for  the  nurse  and  saying  that  he  felt 
something  had  burst  inside  him.  He  expectorated  several  spit- 
cupfuls  within  a  short  time  of  a  dirty,  yellowish-green  pus.  The 
odor  was  not  offensive  ;  microscopically,  it  showed  degenerated  pus 


Fig.  24.— Outline  of  the  liver  and 
situation  of  the  tumor  in  Case 

xxvm. 


TUMORS  OF   THE   LIVER.  77 

cells  ;  no  amoebae.  An  interesting  feature  is  that  on  the  following 
day  the  prominence  in  the  right  epigastric  region  had  almost  disap- 
peared. The  physical  signs  at  the  right  back  had  not  changed. 
Over  the  area  of  dullness  the  respiratory  murmur  was  simply  enfee- 
bled, and  there  were  a  few  fine  rales  on  coughing.  The  temperature 
range  was  from  subnormal  to  102°;  once  only,  after  a  chill,  103  "3°. 
He  was  repeatedly  advised  to  have  an  operation,  but  declined,  saying 
that  he  would  sooner  take  his  chances.  The  expectoration  of  puru- 
lent matter  continued,  but  in  diminishing  quantities  ;  thus  on  the 
23d  it  was  one  hundred  and  twenty  cubic  centimetres  ;  by  the  26th, 
thirty  cubic  centimetres  ;  and  on  the  28th,  forty  cubic  centimetres. 
On  August  1st  it  had  fallen  to  only  ten  cubic  centimetres  ;  on 
the  3d  he  had  none,  and  on  the  6th  only  ten  cubic  centimetres.  No 
amcebse  were  found,  only  pus  cells,  most  of  them  in  a  condition  of 
disintegration.  On  August  8th  he  was  taken  home  by  his  brother, 
the  condition  not  having  materially  improved,  and  the  temperature 
still  ranging  from  98°  to  102°,  occasionally  to  103°.  The  prominent 
mass  on  the  right  side  never  reappeared.  On  discharge,  the  liver 
flatness  began  in  the  fifth  interspace  in  the  nipple  line  ;  the  border 
could  be  felt  five  centimetres  below  the  costal  margin.  In  the  mid- 
axilla  there  were  thirteen  and  a  half  centimetres  of  vertical  dull- 
ness. In  the  median  line  from  the  upper  limit  of  flatness  to  the 
lower  border,  determined  by  palpation,  was  fourteen  centimetres. 

Case  XXIX.  Acute  Dysentery ;  Abscess  of  the  Left  Lobe  of 
the  Liver;  Tumors  in  the  Left  Epigastric  Region;  Incision; 
Death.— Rsqphsiel  F.,  tailor,  aged  twenty-seven  years,  admitted 
August  22,  1893.  His  family  history  is  good.  Patient  is  a  Russian, 
and  has  been  in  this  country  only  nine  years.  Has  been  always 
healthy  and  strong. 

Present  illness  began  abruptly  about  a  month  ago  with  an 
attack  of  vomiting  and  purging ;  had  six  or  eight  stools  the  first  day. 
The  next  day  he  was  rather  better  and  was  pretty  well  for  two  or 
three  days.  Then  he  again  had  vomiting  and  much  purging. 
Evidently  the  attack  was  one  of  acute  dysentery,  as  he  had  numer- 
ous stools  containing  slime  and  blood,  passed  with  much  straining 
and  tenesmus.  He  does  not  think  he  had  at  this  time  any  fever. 
He  has  lived  almost  entirely  on  milk.  The  diarrhoea  has  continued 
ever  since.     On  admission,  he  was  thin,  lips  and  mucous  mem- 


78 


THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 


branes  of  good  color;  tongue  covered  with  a  thick,  white  coating. 
The  temperature  was  97°.  The  examination  of  the  thoracic  organs 
was  negative.  The  abdomen  was  retracted ;  patient  complained  of 
pain  on  palpation  over  the  caecal  region.  The  liver  dullness  be- 
gan in  the  sixth  interspace  in  the  nipple  line  and  extended  to  the 
costal  border.  The  edge  was  not  palpable.  He  had  three  stools 
within  the  first  twenty-four  hours,  brownish  in  color,  fluid,  and 
containing  small  strings  of  mucus.  In  the  mucus  obtained  by  pass- 
ing the  rectal  tube  numbers  of  actively  moving  amoebae  were 
found.  He  was  ordered  large,  high  injections  of  sulphate  of  qui- 
nine— one  to  two  thousand — and  a  milk  diet.  During  the  first  week 
in  hospital  there  was  no  special  change.  The  passages  were  from 
four  to  seven  in  twenty -four  hours.  The  temperature  was  never 
above  99°,  and  he  seemed  to  be  doing  well.  For  the  next  two  weeks 
also  he  seemed  to  be  very  comfortable.  The  temperature  between 
August  29th  and  September  11th  was  not  above  normal.  The  dys- 
enteric symptoms  had  improved  very 
much,  and  from  September  9th  to  the 
13th  he  had  only  had  one  or  two 
movements  a  day.  On  September 
11th  he  made,  for  the  first  time,  com- 
plaint of  a  pain  in  the  epigastric  re- 
gion, and  there  had  been  for  two  days 
slight  fever,  the  temperature  rising  to 
100°.  There  was  a  little  sensitiveness 
over  the  liver  in  the  middle  line,  but 
the  organ  did  not  appear  to  be  en- 
larged. On  September  17th  there  was 
noticed  for  the  first  time  a  rounded 
prominence  occupying  the  left  half  of 
the  epigastric  region,  which  moved  up 
and  down  with  respiration  and  which 
pulsated  with  each  heart  beat.  It  ex- 
tended from  the  costal  margin  in  the 
parasternal  line  to  a  little  beyond  the  middle  line.  It  was  rounded, 
smooth,  firm,  but  elastic,  and  did  not  appear  to  fiuctuate.  The  pul- 
sation was  very  marked  and  seemed  almost  expansile.  On  placing 
the  patient,  however,  in  the  knee-elbow  position  the  pulsation  en.- 


FiG.  25.— Outline  of  the  liver  and 
situation  of  the  tumor  in  Case 
XXIX. 


TUMORS  OF  THE  LIVER.  79 

tirely  ceased;  no  bruit  was  heard  over  it.  The  situation  of  the 
tumor  is  indicated  in  the  annexed  diagram.  The  liver  dullness  be- 
gan at  the  sixth  rib  and  extended  just  belov/  the  costal  margin  in 
the  nipple  line.  In  the  parastci'nal  line  it  did  not  begin  until  the 
seventh  rib,  and  in  the  middle  line  the  dullness  was  about  the  mid- 
dle of  the  ensiforra  cartilage  and  was  then  continuous  with  the 
tumor  mass  on  the  left  side.  In  the  midaxillary  line  the  dullness 
began  at  the  seventh  rib  and  extended  to  the  costal  border.  The 
splenic  dullness  could  not  be  obtained,  nor  could  the  margin  be  felt. 
There  was  no  increase  in  the  hepatic  dullness  behind. 

On  the  18th  the  temperature  rose  to  101  "2°,  the  highest  point 
reached,  and  the  patient  had  no  chills,  but  was  sweating  profusely. 
The  tumor  was  more  prominent;  was  very  tender,  but  there  were 
no  signs  of  fluctuation.  The  diagnosis  of  abscess  of  the  liver  was 
made  and  the  case  was  transferred  to  the  surgical  wards.  Dr. 
Finney  operated,  found  the  peritonaeum  adherent  to  the  liver,  and 
opened  a  supei'ficial  abscess  in  the  left  lobe.  About  seventy -five 
cubic  centimetres  of  thick,  yellowish-green  pus  were  evacuated,  in 
which  amoebae  were  present.  The  patient  stood  the  operation  very 
well,  but  he  bec?.*.ne  progressively  weaker.  The  temperature  never 
rose  above  101  5.     He  died  on  the  24th. 

The  situation  of  the  palpable  tumor  in  liver  abscess  is 
well  illustrated  by  these  four  patients.  In  Case  XXVI  it 
•was  in  the  right  lumbar  and  right  side  of  the  umbilical  re- 
gions, entirely  below  the  costal  margin.  In  Case  XXVIII 
it  was  in  the  right  hypochrondriac  region.  In  Case 
XXVII  it  was  median,  projecting  prominently  midway 
between  the  navel  and  ensiform  cartilage;  and  in  Case 
XXIX  it  was  entirely  to  the  left  of  the  middle  line  in  the 
upper  quadrant  of  the  epigastric  region. 

In  the  diagnosis  of  liver  abscess  you  must  take  into 
consideration  the  following  points : 

Antecedent  Conditions. — Dysentery  is  in  this  latitude 
by  far  the  most  common,  though  it  was  only  present  in 
one  of  the  four  cases  I  have  narrated.  Of  the  nine  cases, 
however,  under  observation  during  the  past  year,  dysen- 


80  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

tery  occurred  in  six  cases.  There  may,  however,  be  no 
recognizable  canse,  as  in  Cases  XXYI,  XXVII,  and 
XXVIII.  Bear  in  mind  that  when  the  patient  comes  be- 
fore you  with  chills  and  fever,  a  sallow  cachexia,  and  an  en- 
larged, tender  liver,  the  dysenteric  symptoms  may  have  en- 
tirely disappeared,  or  there  may  be  only  at  intervals  slight 
recurrences.  Under  these  circumstances  a  catheter  or  the 
long  rectal  tube  passed  into  the  bowel  may  bring  away 
portions  of  mucus  containing  the  amoebae,  associated  with 
the  severer  form  of  dysentery. 

Toxic  Features. — Irregular  fever,  chills,  and  sweats  are 
rarely  absent.  The  sallow  tint  of  the  skin,  the  progressive 
anaemia,  and  the  paroxysms  of  intermittent  fever  lead  very 
frequently  to  a  diagnosis  of  malaria. 

Local  Symptoms, — Increase  in  the  size  of  the  liver  and 
tenderness  on  pressure  are  the  most  important.  The  en- 
largement is  most  frequently  of  the  right  lobe,  but  the 
whole  organ  may  be  greatly  increased  in  size  and  extend 
below  the  navel.  When  the  abscess  is  in  the  right  lobe 
the  enlargement  may  be  chiefly  behind,  ascending  high 
into  the  right  pleura.  Prominent  bulging  of  the  lower  por- 
tion of  the  right  side  of  the  thorax  is  extremely  common. 

And  lastly,  and  what  interests  us  here  especially,  a  tu- 
mor mass  may  develop  beneath  the  right  costal  margin  or 
in  the  epigastric  region.  The  tumor  is  usually  (always 
when  recent)  tender;  often  develops  with  rapidity.  The 
rapid  increase  in  size  with  tenderness,  however,  is  not  to 
be  relied  on  as  characteristic,  as  I  will  mention  to  you  in 
the  fourth  of  the  cases  in  the  cancer  series  this  was  a  very 
marked  feature.  Fluctuation  may  be  obtained  readily 
when  the  tumor  mass  becomes  superficial.  The  tumor 
may  persist,  as  in  Case  XXVI,  for  months  without  very 
much  change.  With  or  without  the  presence  of  tumor, 
when  liver  abscess  is  suspected,  the  long  aspirator  needle 
should  be  freely  used. 


TUMORS  OF  THE  LIVER. 


81 


III.  Syphilis  of  the  Liver. — Of  four  cases  diagnosti- 
cated during  life  as  syphilis  of  the  liver,  two  presented 
definite  tumors.  Diffuse  syphilitic  hepatitis  does  not  pro- 
duce a  tumor,  but  gummata,  either  in  the  inherited  or  ac- 
quired disease,  may  form  tumors  in  two  stages :  first,  when 
fresh  and  developing,  constituting  nodular  masses  of  large 
size,  which  may  persist  for  months  ;  and,  second,  gummata 
which  have  undergone  cicatricial  contraction  and  healing 
may  so  fissure  and  divide  the  liver  by  bands  of  connective 
tissue  that  an  extremely  nodular,  irregular  mass  may  oc- 


FiG.  26.— Showing  the  extreme  irregularity  of  a  syphilitic  liver. 

cupy  the  right  hypochondrium.  Of  the  four  patients  this 
year,  two  died,  but  in  neither  of  them  were  tumors  felt.  I 
show  you  here  a  photograph  of  the  liver  of  one  of  them 
(Fig.  26),  which  will  give  you  an  idea  of  the  extraordinary 


82  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

subdivision  of  the  organ,  an  extreme  grade  of  which  forms 
the  so-called  "  botryoid  "  liver,  in  which  globular  masses  of 
normal  tissue  are  held  together  by  fibrous  bands.  The 
other  case  also,  which  came  to  autopsy,  had  an  extremely 
irregular  liver,  and  was  of  exceptional  interest,  inasmuch 
as  the  recurring  ascites,  for  which  she  had  been  tajiped  re- 
peatedly, disappeared  entirely  under  iodide  of  potassium, 
as  did  also  nodes  on  her  shins.  In  the  following  cases 
definite  tumor  masses  were  present  and  the  correctness  of 
the  diagnosis  in  both  instances  was  in  a  measure  borne  out 
by  the  therapeutic  test.  In  anomalous  tumors  of  the  liver 
it  is  well  to  bear  in  mind  that  gummata  may  form  flat  or 
nodular  masses  in  the  epigastric  region  *  which  may  per- 
sist for  a  long  time,  and  which  may,  under  treatment,  dis- 
appear  as    satisfactorily  as  gummata   of  the  long   bones 

*  A  case  illustrating  an  error  in  diagnosis  is  that  of  hospital  number 
5234,  Joshua  M.,  aged  fifty-four,  admitted  May  16, 1893,  with  swelling  of  the 
abdomen  and  an  illness  of  nearly  a  year's  duration.  The  patient  was  a 
large,  powerfully  built  man;  had  always  enjoyed  good  health,  and  denied 
venereal  disease.  For  nearly  a  year  he  had  had  trouble  in  the  abdomen,  and 
had  twice  been  slightly  jaundiced.  The  legs  had  been  swollen,  and  he  had 
had  shortness  of  breath.  The  examination  showed  an  enormously  enlarged 
liver.  The  whole  of  the  upper  part  of  the  abdomen  was  filled  with  a  hard, 
irregular,  nodular  mass,  corresponding  to  the  greatly  enlarged  liver.  The 
lower  border  was  felt  midway  between  the  umbilicus  and  the  pubes.  There 
were  prominent  bosses  on  the  surface  of  the  liver,  and  from  its  great  size 
and  irregularity  there  seemed  to  be  no  question  as  to  the  correctness  of 
the  diagnosis  of  secondary  cancer  of  the  organ.  No  primary  disease  could  be 
determined,  and  there  was  decided  hyperacidity  of  the  gastric  juice.  The 
patient  remained  in  the  hospital  for  a  month  and  gained  slightly  in  weight, 
but  the  liver  developed  still  further,  and  the  irregularity  on  the  surface  was 
more  marked.  An  aspirator  needle  was  thrust  in,  but  nothing  but  blood 
obtained.  Naturally  enough  the  diagnosis  was  entered  as  cancer  of  the 
liver.  Dr.  E.  T.  King,  of  Washington,  under  date  of  February  10,  1894, 
writes  that  he  has  Joshua  M.  under  his  care  at  present.  He  has  a  well- 
marked  syphilitic  skin  eruption,  and  the  liver,  still  enlarged,  extends  nearly 
to  the  pelvis.  The  time  element  in  this  case,  I  should  think,  definitely  ex- 
cludes cancer,  while  the  syphilitic  rash  on  the  skin  is  suggestive  in  the  high- 
est degree  that  the  whole  trouble  is  specific.  On  the  death  of  this  patient  in 
the  spring  of  1894,  Dr.  Lamb,  who  made  the  autopsy,  stated  that  it  was 
cancer  of  the  liver,  an  instance  of  unusually  long  duration. 


TUMORS  OP   THE   LIVER.  83 

or  of  the  testes.  One  of  the  first  private  patients  who  ap- 
plied at  the  hospital  was  a  young  man  aged  about  twenty- 
eight  years,  who  presented  just  below  the  ensiform  a  flat 
tumor  mass  evidently  attached  to  the  liver,  the  nature  of 
which  had  been  very  much  discussed.  He  was  sent  to  me 
for  an  opinion  as  to  the  advisability  of  a  laparotomy.  A 
positive  history  of  syphilis  was  obtained  and  he  was  urged 
to  have  a  thorough  course  of  treatment.  I  did  not  see  him 
again  for  nearly  a  year,  when,  to  my  astonishment,  the  tu- 
mor had  practically  disappeared. 

Case  XXX.  Prominent  Tumor  Mass  in  the  Epigastrium; 
Disappearance  in  Four  Months  under  the  Use  of  Iodide  of  Potas- 
sium.— John  C,  aged  thirteen  years,  seen  November  11th  with  Dr. 
Thayer.  He  had  been  in  hospital  during  my  absence  in  the  sum- 
mer with  a  tumor  connected  with  the  liver.  The  notes  made  at 
the  time  are  as  follows  :  Admitted  July  13,  1892,  complaining  of 
pain  in  the  right  hypochondrium. 

The  father  is  living  and  is  paralyzed  ;  mother  is  living  and 
well  ;  two  sisters  and  one  brother  died  young  ;  has  three  brothers 
and  four  sisters  living. 

As  a  child  he  was  well,  with  the  exception  of  enlarged  glands, 
which,  at  about  his  fourth  year,  appeared  on  the  right  side  of  the 
neck  and  discharged  for  nearly  three  years. 

His  present  illness  began  about  three  months  ago  with  pain  in 
the  right  side,  which  has  continued,  and  two  weeks  ago  became 
much  worse  ;  the  abdomen  became  swollen,  particularly  in  the 
upper  zone  and  to  the  right  side.  The  feet  have  never  been  swoll- 
en nor  has  he  had  any  swelling  of  the  face.  Since  his  illness  be- 
gan there  has  been  pt'ogressive  loss  of  weight,  and  he  frequently 
sweats  profusely  at  night. 

Present  Condition. — Poorly  nourished  and  not  very  well  de- 
veloped lad.  Lips  and  mucous  membranes  of  a  good  color. 
Skin  clear,  not  jaundiced.  Scars  on  the  neck  just  below  the  right 
ear  and  one  on  the  episternal  notch.  The  cervical  glands  are  not 
enlarged  ;  the  inguinal  glands  are  only  just  palpable.  The  epi- 
trochlear  glands  are  enlarged  ;  there  are  no  nodes,  though  about 
the  middle  of  the  right  tibia  there  is  a  slight  roughening.     There 


84:  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

are  rhagades  at  the  angles  of  the  mouth  ;  the  corneae  are  clear  ; 
the  upper  central  incisors  are  well  formed.  Examination  of  the 
blood  is  negative. 

The  thorax  is  somewhat  expanded  in  the  lower  part,  particiilarly 
on  the  right  side.  Examination  of  the  lungs  and  of  the  heart  is 
negative. 

The  abdomen  is  prominent  in  epigastric  and  right  hypochon- 
driac regions.  The  hepatic  flatness  begins  in  the  sixth  interspace 
in  the  nipple  line  and  extends  two  fingers'  breadth  below  the  cos- 
tal margin.  The  epigastrium  is  filled  with  a  firm,  hard  mass, 
which  appears  to  be  the  left  lobe  of  the  liver  or  a  mass  continuous 
with  it.  It  extends  in  the  median  line  within  two  centimetres  of 
the  umbilicus,  and  a  slight  notch  can  be  felt.  The  surface  is  some- 
what irregular  and  a  distinct  rounded  nodule  can  be  felt  a  little 
above  and  to  the  right  of  the  navel.  In  the  nipple  line  the  edge  of 
the  liver  is  diflScult  to  feel,  as  the  abdominal  walls  are  rigid.  The 
splenic  flatness  begins  at  the  seventh  rib  and  is  continuous  with 
that  of  the  mass  in  the  epigastrium.  The  edge  of  the  spleen  is  not 
palpable. 

The  urine  was  clear,  lemon-colored  ;  no  albumin  ;  no  tube 
casts.  He  had  slight  fever  ;  temperature  on  admission  100-5°  F., 
and  every  day  for  a  week  it  rose  to  100°  F.  The  patient  was 
placed  upon  iodide  of  potassium,  five-grain  doses  three  times  a 
day,  increasing  rapidly  until  he  took  a  drachm  three  times  a  day. 
He  improved  in  weight  and  gained  seven  pounds  within  a  month. 
The  mass  in  the  epigastrium  gradually  disappeared. 

The  condition  to-day,  November  11th,  is  as  follows  : 

The  boy  has  grown  somewhat,  though  he  looks  thin.  The 
tongue  is  clean  ;  the  lips  and  mucous  membranes  are  of  good 
color.     He  has  no  cough. 

He  certainly  has  not  a  luetic  facies,  though  the  s'cars  at  the 
angle  of  the  mouth  are  suggestive.  The  edge  of  the  liver  does  not 
appear  to  be  below  the  costal  border  in  the  nipple  line  ;  flatness 
begins  at  the  sixth  rib  in  the  nipple  line.  Palpation  in  the  epigas- 
tric region  is  negative  until  the  extremity  of  the  angle  is  reached, 
and  here,  just  below  the  tip  of  the  ensiform  cartilage,  can  be  felt 
a  hard,  firm  ridge  with,  in  the  right  xiphoid  angle,  a  little  promi- 
nent projection  the  size  of  a  walnut.     Just  to  the  left  of  the  tip 


TUMORS  OF  THE  LIVER. 


85 


of  the  ensifortn  cartilage  a  second  prominent  but  smaller  eleva- 
tion can  be  felt.  The  one  to  the  left,  when  he  draws  a  deep 
breath,  can  be  seen  distinctly  in  the  descent  of  the  liver  as  a  slight 
prominence  beneath  the  skin.  The  edge  of  the  liver  comes  about 
a  finger's  breadth  below  the  tip  of  the 
ensiform  cartilage  and  fills  up  the  en- 
tire left  costo-xiphoid  angle. 

This  case  is  similar  in  some  re- 
spects to  one  reported  from  my  clinic 
at  the  University  Hospital  by  Dr.  A. 
C.  Wood,*  the  history  of  which  is  so 
interesting  that  I  abstract  it  here  : 
"  He  had  an  eruption  on  the  skin 
when  six  months  old.  Did  not  have 
snu£B.es.  Has  always  been  robust. 
For  several  months  back  his  mother 
has  noticed  his  abdomen  becoming 
more  and  more  prominent.  The  pa- 
tient has  lost  flesh  of  late.  Has  had 
no  jaundice.  The  boy,  aged  thirteen, 
is  fairly  well  grown,  well  nourished, 
looks  a  little  pale  ;  abdomen  promi- 
nent, and  on  the  right  side  between  the  navel  and  the  costal  mar- 
gin there  is  a  dfstinct  hemispherical  swelling  about  two  inches  in 
diameter.  The  tumor  descends  slightly  on  inspiration.  The  super- 
ficial abdominal  veins  are  not  especially  dilated.  The  upper  teeth 
are  not  good,  but  are  not  notched.     He  has  not  a  syphilitic  facies. 

"  On  palpation,  the  lower  zone  of  the  abdomen  is  soft.  In  the 
left  hypochondriac  region  the  edge  of  the  spleen  is  distinctly  felt, 
with  its  notch  at  least  two  fingers*  breadth  below  the  costal  mar- 
gin. Toward  the  right  hypochondrium  a  firm,  solid  mass  is  felt, 
the  edge  of  which  is  ill-defined  below  and  to  the  right.  Above,  it 
seems  to  pass  directly  beneath  the  costal  margin  in  the  position  of 
the  liver.  The  tumor  is  painless.  The  liver  dullness  begins  in  the 
midsternal  line  at  the  level  of  the  sixth  costal  cartilage,  in  the  nip- 
ple line  at  the  upper  border  of  the  fifth  rib,  and  is  directly  con- 


FiG.  2r.-The  situation  of  the  tu- 
mor nodules  in  Case  XXX. 


*  University  Medical  Magazine,  vol.  ii. 


86  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

tinuous  with  that  of  the  tumor  and  reaches  to  within  a  finger's 
breadth  of  the  navel.  In  the  axillary  line  there  is  dullness  from 
the  upper  border  of  the  eighth  to  the  lower  border  of  the  tenth 
rib.  The  left  lobe  of  the  liver  does  not  appear  to  be  enlarged. 
The  splenic  dullness  begins  at  the  upper  border  of  the  eighth 
rib  and  extends  two  fingers'  breadth  below  the  costal  border. 

"  Fowler's  solution  was  prescribed,  four  minims  three  times 
daily,  to  be  increased  by  one  drop  each  week.  This  was  taken  at 
intervals  until  the  middle  of  January,  about  five  months,  when  it 
became  necessary  to  discontinue  it  on  account  of  nausea  and 
vomiting.  During  this  time  the  color  of  the  face  had  improved, 
the  tumor  had  enlarged,  and,  on  deep  inspiration,  the  margin  now 
reached  the  navel,  and  it  was  rough  on  the  surface. 

"  In  October,  1888,  the  patient  complained  of  pain  in  both  tibiae. 
The  pain  was  thought  to  be  periosteal,  and  five  grains  of  iodide  of 
potassium  were  ordered  to  be  taken  three  times  a  day.  When  seen 
again,  two  months  later,  the  tumor  was  more  nodular,  the  spleen 
had  increased  in  size,  extending  three  inches  below  the  costal  mar- 
gin. The  general  condition  of  the  patient  remained  good.  He  was 
now  given  one  grain  of  calomel  three  times  daily,  and  instructed  at 
the  end  of  three  weeks  to  intermit  for  a  week.  This  was  continued 
with  similar  intermissions  for  about  six  months,  with  gradual  im- 
provement in  appetite,  color,  and  general  health." 

After  leaving  Philadelphia  the  boy  came  under  the  care  of  Dr. 
A.  C.  Wood,  who  reported  that  he  returned  to  the  hospital  in  Feb- 
ruary, 1890,  and  the  mother  thought  there  had  been  a  slow  im- 
provement. There  was,  however,  on  the  forehead  a  small  region 
of  necrosis  of  the  frontal  bone  about  the  size  of  a  ten  cent  piece, 
which  had  followed  a  definite  node.  The  interesting  thing  is  that 
the  hemispherical  swelling  in  the  hepatic  region,  which  was  so 
striking  in  this  case,  had  practically  disappeared.  I  demonstrated 
this  case  on  several  occasions  before  my  class  in  the  session  of 
1887-'88  and  of  1888-'89,  and  on  each  occasion  the  hemispherical 
swelling  on  the  right  side,  between  the  ravel  and  the  costal  mar- 
gin, was  unusually  distinct — so  much  so  that  it  could  readily  be 
seen  by  the  students  from  the  most  distant  benches  of  the  amphi- 
theater. I  confess  that  tmtil  October,  1688,  when  there  were  pains 
of  the  tibiae,  I  did  not  think  the  case  syphilitic,  but  regarded  it  as 


TUMORS  OF  THE  LIVER.  8T 

an  anomalous  tumor  of  the  organ.  In  October,  1888,  howevei',  he 
was  given  iodide  of  potassium  and  subsequently  calomel.  Its 
syphilitic  nature  seems  to  be  definitely  established  by  the  develop- 
ment of  the  gummatous  tumor  on  the  forehead,  which  subse- 
quently broke  down  and  left  a  patch  of  necrosis. 

Case  XXXI.  Syphilis  of  the  Liver ;  Convulsions  ;  Right 
Hemiplegia ;  Irregular  Tumor  over  the  Left  Lobe. — On  May  3d 
J.  M.,  aged  forty -seven  years,  returned  by  appointment  to  report 
on  his  condition.  I  had  not  seen  him  since  the  25th  of  September 
of  last  year.  The  case  is  one  of  a  good  deal  of  interest  with  refer- 
ence to  the  diagnosis  and  treatment  of  syphilis  of  the  liver.  I  saw 
him  first  in  March,  1893. 

The  patient  is  a  stout  man,  well  built,  but  looks  ten  years  older 
than  the  age  he  gives.  He  is  a  traveling  salesman,  and,  in  re- 
sponse to  an  inquiry  as  to  his  habits,  gave  the  characteristic  reply 
that  "  he  took  his  luck  on  the  road."  He  had  syphilis  in  1866,  and 
was  treated  for  some  time.  For  eighteen  months  or  more  he  had 
been  complaining  of  dyspepsia  and  irregular  pains  in  the  abdomen. 
In  December,  1890,  he  had  vomiting,  and  last  March,  just  a  year 
ago,  the  pains  were  very  severe — so  much  so  that  he  had  to  have  a 
hypodermic  injection  of  morphine.  He  had  no  jaundice  after  this 
attack.  He  went  to  the  country,  stayed  until  June,  and  improved 
a  great  deal,  but  he  had  there  another  severe  attack  of  pain  in  the 
abdomen.  Through  the  summer  he  lost  thirty-five  pounds  in 
weight.  In  the  autumn  he  had  an  attack  of  jaundice  which  lasted 
for  nearly  two  months  and  gradually  disappeared.  This  jaundice 
set  in  with  pains,  which  were  very  severe.  Two  months  ago,  while 
sitting  in  his  office,  he  fell,  lost  consciousness,  had  a  convulsive 
seizure,  followed  by  left  hemiplegia.  Gradually  the  power  re- 
turned. He  had  another  convulsive  seizure,  with  loss  of  conscious- 
ness, a  week  ago,  not  followed  by  paralysis. 

When  seen,  March  24th,  he  was  well  nourished,  not  jaundiced. 
The  point  of  special  note  was  the  examination  of  the  abdomen. 
The  panniculus  was  thick ;  the  liver  was  enlarged.  The  right  lobe 
felt  somewhat  irregular,  but  there  were  no  definite  nodules.  The 
gall-bladder  was  not  palpable.  In  the  left  hypochondriac  region, 
emerging  beneath  the  costal  border,  was  a  flat  tumor  mass,  which 
extended  in  the  parasternal  line  nearly  to  the  level  of  the  navel. 


83  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

It  was  sensitive,  firm,  felt  about  the  size  of  the  palm  of  the  hand, 
and  descended  with  inspiration.  It  was  superficial,  no  definite 
edge  could  be  felt,  and  to  the  right  it  could  be  separated  clearly 
from  the  edge  of  the  liver  (right  lobe)  in  the  right  parasternal  line. 
On  percussion,  its  dullness  could  be  separated  defi-uitely  from  that 
of  the  spleen. 

Of  course,  the  attacks  of  pain,  one  of  which  was  followed  by 
jaundice,  were  very  suggestive  of  gallstones.  On  the  other  hand 
the  anomalous  character  of  the  tumor  mass  attached  to  the  left 
lobe  of  the  liver,  the  fact  that  he  had  had  syphilis,  and  that  he  had 
had,  without  obvious  cause,  two  convulsive  seizures,  made  me  sus- 
pect that  possibly  the  mass  on  the  liver  was  syphilitic  in  character. 
He  was  ordered  thirty  grains  of  iodide  of  potassium  three  times  a 
day. 

On  the  16th  of  April  I  saw  him  again,  after  he  had  had  for  a 
week  or  more  a  very  severe  attack  of  nausea  and  vomiting.  The 
mass  referred  to  was  very  evident.  A  feature  of  interest  was  the 
development,  about  a  month  after  beginning  to  take  iodide  of 
potassium,  of  an  acute  parotiditis  on  the  right  side,  probably  sec- 
ondary to  the  abdominal  disease,  such  as  Stephen  Paget  has  so  well 
described. 

I  saw  the  patient  again  on  September  25th.  He  had  had  no  at- 
tacks, no  jaundice,  no  pains,  and  had  not  had  a  convulsion  for  five 
months.  He  has  taken  the  iodide  at  intervals.  Lately  he  has  had 
an  ulcer  on  one  tendo  Achillis,  which  was  very  troublesome,  but  is 
now  healing.  He  has  gained  in  weight,  has  been  able  to  attend  to 
his  work,  and  looks  very  well.  The  tumor  mass  which  was  so  per- 
ceptible in  the  left  hypochondriac  region  has  almost  disappeared. 
The  edge  of  the  left  lobe  of  the  liver  can  be  distinctly  felt. 

May.  3d. — He  reports  that  he  has  kept  well  all  through  the 
winter.  He  has  had  no  attacks  of  abdominal  pain,  no  convul- 
sions. He  has  gained  in  weight ;  looks  well.  The  condition  of 
the  liver  is  practically  negative.  Nothing  definite  to  be  felt  in 
the  left  lobe,  only  slight  irregularity  as  it  descends  in  deep  in- 
spiration. 

IV.  Cancer  of  the  Liver. — "With  the  exception  of  the 
fibromyoma  of  the  uterus,  cancer  of  the  liver  may  consti- 


TUMORS  OF  THE  LIVER. 


89 


tute  the  largest  tumor  met  with  in  the  abdomen.  In  ex- 
treme cases,  as  in  the  photographs  I  here  show  you,  the 
entire  cavity  is  occupied  by  the  enormously  enlarged  liver. 
The  diagnosis  is  not  difficult,  particularly  in  the  secondary 


Fia.  28.— Cancer  of  the  liver,  showing  the  enormous  increase  in  the  area  of  dullness.    The 
shaded  areas  show  the  situation  of  the  visible  tumor  masses. 

cancer  with  great  enlargement  of  the  organ.  Cases  of  pri- 
mary cancer,  and  especially  the  peculiar  form  of  "  cancer 
with  cirrhosis,"  may  be  extremely  difficult  to  recognize.  A 
very  large  proportion  of  all  cases  are  secondary,  and  char- 
acterized by  a  very  rapid  growth,  profound  cachexia,  and 


90  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

often  jaundice.  The  new  growth  may  be  so  diffusely  scat- 
tered throughout  the  organ  that  the  enlargement  is  uni- 
form and  the  surface  is  smooth ;  but  more  commonly  there 
are  large  outgrowths  on  the  surface  or  at  the  edge  of  the 
liver,  which  form  prominent  tumors  of  the  greatest  value 
in  diagnosis.  Not  infrequently,  indeed,  they  project  be- 
yond the  surface  of  the  liver  far  enough  to  be  seen  through 
the  thin  abdominal  walls,  as  in  this  photograph  from  a  case 
in  the  hospital  last  year  (Fig.  28).  In  a  patient  with  cancer 
of  the  liver  (secondary  to  disease  of  the  csecum)  who  re- 
cently died  on  the  surgical  side,  these  masses  were  of  great 
prominence,  as  this  photograph  shows  (Fig.  29).  These 
nodules  are  known  in  the  older  literature  as  Farre's  tuber- 
cles of  the  liver.  They  vary  in  size  from  a  walnut  to  an 
orange ;  they  are  usually  firm  and  hard,  the  edges  rounded, 
and  the  centers  cupped — a  sort  of  umbilication  caused  by 
the  fibroid  and  degenerative  changes  going  on  in  the  cen- 
tral portion  of  the  mass.  Frequently  these  characters  can 
be  determined  on  palpation,  and  are  of  special  importance 
in  diagnosis.  In  the  following  cases  tumor  masses  were 
present : 

Case  XXXII.  Cancer  of  the  Liver;  Chills,  Fever,  and  Siveats. 
— Mrs.  S.,  aged  sixty -nine  years,  seen  with  Dr.  Amanda  Norris  on 
April  30th.  Family  history  good;  husband  died  in  1879  of  cancer 
of  the  stomach. 

The  patient  has  been  a  strong,  healthy  woman.  During  the 
past  winter  has  not  been  in  good  health,  has  been  losing  in  weight, 
and  has  had  indigestion.  She  has  kept  about,  and  the  condition 
was  not  thought  to  be  serious  until  March  4th,  when  she  had  a 
severe  chill  with  pair  in  the  right  side.  There  was  no  cough,  no 
signs  of  any  pleural  or  pulmonary  trouble,  nor  had  she  any  jaun- 
dice. The  chills  recurred  very  frequently,  sometimes  every  day; 
she  was  in  bed  for  three  weeks.  The  fever  rose,  and  she  had 
heavy  sweats.  She  had  also  marked  gastric  symptoms,  and  vom- 
ited almost  every  day;  never  brought  up  any  blood,  and  never 
very  large  quantities.     She  got  somewhat  better,  and  for  a  couple 


10 


92  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

of  weeks  was  up  and  about  and  seemed  improving,  and  she  had  no 
chills.  During  the  past  three  weeks  the  chills  and  fever  have  been 
again  present,  and  she  has  had  vomiting  and  inability  to  take 
much  food.  The  temperature  goes  up  to  102°  and  103°,  and  the 
chills  are  sometimes  severe.  The  bowels  have  been  constipated; 
she  has  never  had  any  jaundice. 

Present  Condition. — Patient  is  not  cachectic-looking;  face  has 
a  grayish,  rather  anaemic  aspect.  Tongue  is  slightly  furred.  Ex- 
amination of  the  thoracic  organs  is  negative. 

The  abdomen  is  somewhat  full;  panniculus  moderately  thick; 
the  upper  zone  of  the  abdomen  a  little  prominent.  On  palpation, 
it  is  everywhere  soft  on  the  left  side  and  below.  Occupying  the 
upper  umbilical  and  all  of  the  epigastric  regions  and  extending  to 
the  right  in  an  oblique  line  toward  the  anterior  superior  spine 
there  is  a  solid  resistant  mass,  which  descends  on  inspiration.  It 
is  evidently  a  greatly  enlarged  liver.  In  the  anterior  axillary  line 
the  edge  descends  unusually  low,  and  here,  at  a  short  distance  from 
the  anterior  suiierior  spine,  there  is  a  prominent  nodular  mass  as 
large  as  the  top  of  a  lemon,  firm,  hard,  attached  to  the  liver.  It 
gives  one  the  impression  of  a  secondary  nodule.  A  second  mass, 
not  so  largb,  can  be  felt  just  above  the  border  of  the  liver  in  the 
nipple  line,  and  a  third  at  the  edge  of  the  liver,  a  little  beyond  the 
left  upper  sternal  line.  The  upper  limit  of  the  liver  dullness  is 
greatly  extended,  particularly  in  the  nipple  and  anterior  axillary 
lines.  The  stomach  does  not  appear  to  be  dilated.  No  tumor  mass 
to  be  felt  on  deep  pressure  in  the  left  hypochondriac  and  umbilical 
regions;  the  spleen  is  not  enlarged. 

As  usual,  the  chills  in  this  latitude  had  been  taken  to  indicate 
malaria,  and  she  had  been  saturated  with  quinine  for  weeks  with- 
out any  influence.  Chills  with  enlarged  liver  mean  in  the  great 
majority  of  cases  suppuration,  either  abscess  or  pylephlebitis. 
Here  in  a  woman  the  onset  with  pains  and  the  early  chills  sug- 
gest, even  in  the  absence  of  jaundice,  that  the  whole  trouble  may 
depend  upon  gallstones,  and  that  the  chills  may  be  associated  with 
suppurative  cholangeitis. 

Chills  and  fever  may,  however,  occur  in  cancer  of  the  liver, 
and  in  this  case  the  emaciation,  the  enlargement  of  the  organ,  and 
particularly  the   nodular  masses,  suggest   the  presence  of  a  neo- 


TUMORS  OF  THE   LIVER.  93 

plasm.  The  chills  and  fever  may  be  associated  with  the  rapid 
growth  of  cancer,  but  in  the  liver  the  suppuration  may  be  in  some 
of  the  large  bile  ducts,  blocked  with  the  neoplasm.  Dr.  Norris 
wi'ote  that  subsequently  jaundice  developed.  The  fever  persisted, 
and  before  her  death  the  emaciation  was  extreme. 

Case  XXXIII.  Large  Nodular  Tumors  at  the  Edge  and  Sur- 
face of  the  Liver. — Mrs.  S.,  aged  about  fifty  years,  consulted  me 
January  24th,  complaining  of  cough,  loss  of  flesh,  fever,  and  short- 
ness of  breath  on  exertion.  There  was  slightly  deficient  expansion 
at  the  left  apex,  and  a  few  rales  in  the  suprascapular  region.  An 
examination  of  the  sputum  showed  tubercle  bacilli.  I  did  not  see 
the  patient  again  until  October  18th  in  consultation  with  Dr. 
Aaronsohn.  She  had  had  pleurisy  on  the  left  side,  with  some 
effusion,  which  had  alihost  completely  disappeared.  She  had  be- 
come progressively  weaker  ;  had  had  some  loss  of  appetite,  but  no 
marked  gasti'ic  symptoms.  On  examination  of  the  abdomen,  how- 
ever, there  was  felt  a  remarkable  ridge-Hke  tumor  extending  just 
below  the  level  of  the  navel,  with  a  very  hard,  averted,  and  irregu- 
lar edge,  above  which  was  a  sort  of  shallow  groove.  The  abdomen 
was  much  relaxed  ar).d  the  intestines  lay  between  the  abdominal 
wall  and  this  ridge-like  mass.  At  first  I  thought  it  possibly  might 
be  the  omentum  curled  up  and  indurated,  but  on  more  careful 
palpation  it  was  evident  that  the  indurated,  irregular  edge  was 
continuous  with  the  liver.  The  extreme  hardness  and  irregularity 
were,  of  course,  very  suggestive  of  cancer,  in  favor  of  which  also 
were  the  enlargement  and  the  pain  on  pressure. 

I  saw  this  patient  again  in  consultation  on  the  30th  and  31st, 
and  the  two  weeks  which  had  elapsed  had  made  a  very  striking 
change  in  the  condition  of  the  liver.  It  was  considerably  below 
the  level  of  the  navel.  The  irregularity  was  very  much  more  pro- 
nounced, and  definite  nodular  masses  could  be  felt  both  at  the 
edge  and  on  the  surface.  One  of  these,  a  little  to  the  left  of  the 
middle  line,  was  at  least  six  centimetres  in  diameter,  with  a 
rounded  edge  and  a  depressed  center.  The  condition  was  still  a 
little  peculiar  and  unusual  from  the  fact  that  the  abdominal  walls 
were  extremely  relaxed  and  the  intestines  lay  in  front  of  the  liver 
so  that  there  was  resonance  as  high  as  the  costal  margin.  The 
growths  in  the  liver  were,  from  their  local  character,  evidently 


94  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

secondary,  and  though  the  patient  had  profound  anorexia,  there 
was  no  evidence  as  to  the  seat  of  the  primary  disease.  She  died  a 
few  days  after  my  last  visit. 

Case  XXXIV.  Enlargement  of  the  Liver ;  Prominent  Mass 
in  the  Upper  Umbilical  Region  ;  Latent  Cancer  of  the  Stomach. — 
Henry  T.,  aged  fifty-nine  years,  admitted  October  4th,  complain- 
ing of  pain  in  the  abdomen  and  back.    Family  history  is  good. 

Has  been  a  temperate  man  and  has  had  no  serious  illnesses. 
Three  months  ago  he  says  he  was  quite  well.  About  eight  weeks 
ago  noticed  that  he  had  occasional  pain  in  the  abdomen,  which  for 
the  past  four  weeks  has  been  constant  and  of  a  dull  aching  char- 
acter. He  only  stopped  work  three  weeks  ago  ;  has  lost,  he  says, 
thirty  pounds  in  weight  in  two  months.  His  appetite  is  poor  ;  has 
never  had  any  vomiting  ;  has  no  nausea.  Food  makes  no  differ- 
ence in  the  pain.     Two  days  ago  his  feet  began  to  swell. 

Patient  is  a  tall  man,  much  emaciated.  The  skin  has  every- 
where a  sallow  tint,  and  the  conjunctivae  are  slightly  tinged. 
Tongue  moist,  covered  with  a  white  fur.  Condition  of  thoracic 
organs  is  negative.  Abdomen  much  distended  in  epigastric  and 
hypochondriac  regions,  especially  on  the  right  side.  In  the  upper 
part  of  the  umbilical  region  there  is  a  prominent  mass  which  is  to 
be  seen  readily,  and  which  moves  up  and  down  with  respiration. 
On  palpation,  it  is  felt  to  be  separated  by  a  distinct  groove  from 
the  swelling  in  the  right  hypochondriac  and  epigastric  regions. 
The  surface  is  smooth,  painless  ;  no  nodules  are  to  be  felt,  but  on 
the  lower  margin  which  extends  to  the  navel  it  is  distinctly  irregu- 
lar. The  percussion  dullness  does  not  correspond  to  the  edge  of 
the  mass,  but  is  fully  a  hand's  breadth  above  it.  The  upper  limit 
of  dullness  is  at  the  fifth  rib  in  the  nipple  line,  and  at  the  seventh 
in  the  midaxillary.  The  splenic  dullness  is  not  increased  ;  the 
edge  is  not  palpable. 

The  urine  was  dark  brownish-yellow  and  contained  a  faint  trace 
of  albumin. 

There  seemed  no  question  at  all  that  this  was  a  liver  enlarged 
by  cancer,  but  at  first  the  prominent  mass  in  the  umbilical  region, 
which  seemed  separated  from  the  upper  part  by  a  distinct  groove, 
raised  a  slight  doubt  ;  but  the  profound  cachexia,  the  rapid  growth, 
and  the  irregular,  nodular  edge  seemed  conclusive.     The  primary 


TUMORS  OF  THE  LIVER.  95 

trouble  was  not  evident.  The  examination  of  the  rectum  was 
negative.  A  test  breakfast,  withdrawn  fifty  minutes  after,  gave 
fifty  cubic  centimetres  of  a  dirty  reddish-brown  fluid  consisting  of 
undigested  food,  and  showed  a  great  many  blood-cells.  Free 
hydrochloric  acid  was  not  present.  On  the  10th  he  had  been  suf- 
fering a  great  deal  of  pain,  and  following  three  injections  of  a 
sixth  of  a  grain  of  morphine  at  9  A.  M.,  3  P.  M.,  and  10  P.  M.,  he  be- 
came profoundly  comatose,  and  died  at  2  A.  M.  on  the  11th. 

The  autopsy  showed  the  primary  carcinoma  to  be  in  the  stom- 
ach, at  the  greater  curvature,  just  eight  centimetres  from  the  car- 
diac orifice.  The  liver  was  enormously  enlarged  and  weighed  five 
kilogrammes  and  a  half.  The  prominent  tumor  in  the  upper  um- 
bilical region  felt  during  life  corresponded  to  a  new  growth  in  the 
left  lobe  of  the  liver,  which  formed  a  projecting  knob  ten  by  ten 
centimetres  in  extent.  The  entire  organ  was  occupied  with  small 
and  large  secondary  nodules,  very  little  liver  substance  remain- 
ing. The  bile  ducts  were  not  affected.  There  were  secondary 
nodules  of  cancer  in  the  pancreas. 

The  following  case  is  of  great  interest  from  the  local 
character  of  the "  tumor  masses,  which  in  the  epigastric 
region  were  so  prominent,  soft,  and  fluctuating  that  the 
condition  of  abscess  of  the  liver  was  suspected.  It  illus- 
trates, too,  the  importance  of  obtaining  a  thorough  history. 

Case  XXXV.  Sarcoma  of  the  Liver ;  Two  Prominent  Tumor 
Masses  in  the  Epigastric  Region ;  Diagnosis  of  Abscess ;  Ex- 
ploratory Laparotomy. — E.  K.,  aged  nineteen  years,  seen  Septem- 
ber 6,  1892,  with  Dr.  McGill.  Condition  on  visit  was  as  follows  : 
The  most  extreme  grade  of  emaciation,  particularly  of  the  face. 
The  skin  was  bathed  in  perspiration ;  pulse,  104,  of  fair  volume  and 
good  tension  ;  respirations  quiet  ;  no  fever. 

On  exposing  the  abdomen,  the  upper  zone  is  distinctly  full,  and 
two  tumor  masses  are  visible  in  the  middle  line,  the  smaller  and  less 
prominent  just  below  the  ensiform,  and  the  other,  a  larger  hemi- 
spherical mass,  bulges  the  thin,  tense  skin  between  the  ensiform 
cartilage  and  the  navel.  Both  rose  and  fell  with  the  respiratory 
movements.     No  glandular  enlargements  were  visible. 


96  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

On  palpation,  the  superficial  tumor  masses  were  not  tender,  nor 
were  there  any  spots  of  special  sensitiveness  anywhere  over  the 
liver.  The  lower  and  larger  mass  was  soft  and  appeared  to  be 
distinctly  fluctuating.  The  upper  tumor  was  not  quite  so  soft,  and 
fluctuation  could  not  be  obtained  between  the  two.  The  apparent 
fluctuation  was  also  recognized  by  Dr.  Tiffany,  who  had  seen  the 
patient  some  days  before.  A  distinct  ridge,  like  the  edge  of  the 
liver,  could  be  felt  two  fingers'  breadth  above  the  navel  and  ex- 
tended to  the  right,  passing  at  the  anterior  axillary  Kne  beneath 
the  costal  margin,  at  which  point  there  was  a  somewhat  indistinct 
irregularity. 

The  liver  dullness  began  on  the  midsternum  opposite  the  sixth 
costal  cartilage,  and  extended  within  two  fingers'  breadth  of  the 
navel.  In  the  midaxillaiy  line  it  was  at  tbe  eighth  rib  and  the 
dullness  was  not  increased  at  the  right  infrascapular  region. 

The  condition  of  the  heart  and  lungs  was  negative.  The  diges- 
tion was  good  and  he  had  been  taking  plenty  of  nourishment. 
Lately  he  had  had  occasional  attacks  of  diarrhoea. 

The  history  of  the  case  was  not  very  satisfactory.  He  had  been 
a  fairly  healthy  lad,  but  had  some  indefinite  illness  this  summer, 
and  had  gone  out  to  Colorado  with  a  friend.  He  was  there  on  a 
ranch,  and  seemed  to  be  fairly  well  until  about  six  weeks  ago, 
though  he  had  apparently  been  losing  in  weight.  He  became 
much  worse  after  a  long  ride,  and  about  three  weeks  ago  his  father 
was  summoned  and  immediately  went  to  Colorado  and  brought 
him  home.  Since  his  return  the  chief  symptoms  have  been  pro- 
gressive weakness  and  loss  of  flesh.  The  liver  was  found  to  be 
enlarged,  and  the  tumor  masses  above  referred  to  have  within  the 
past  ten  days  become  very  prominent.  There  have  been  no  definite 
chills,  though  he  has  occasional  chilly  feelings.  The  temperature 
has  on  no  occasion  been  elevated  and  not  infrequently  been  sub- 
normal. He  has  had  heavy  sweats,  particularly  during  sleep.  No 
history  could  be  obtained  of  any  attack  like  dysentery,  though  he 
has  had  looseness  of  the  bowels  from  time  to  time. 

The  first  glance  at  the  emaciated  form  of  the  patient  at  once 
suggested  a  new  growth,  but  the  age,  the  quick  onset,  and  more 
particularly  the  examination  of  the  superficial  tumor  masses  and 
their  rapid  increase  in  size,  seemed  to  favor  the  existence  of  abscess. 


TUMORS  OF  THE  LIVER.  97 

Suppurating  hydatid  tumor  could  not  be  definitely  excluded, 
though  the  rapid  course  was  against  this  idea  ;  also  the  profound 
emaciation  which,  though  rare,  is  occasionally  present,  as  in  the 
case  of  an  Italian  who  came  under  my  observation  in  Montreal.* 
I  suggested  the  propriety  of  aspiration  or  of  an  exploratory  inci- 
sion, and  this  the  next  day  Dr.  TiflFany  proceeded  to  do.  I  then 
learned  for  the  first  time  that  in  May,  1891,  more  than  eighteen 
months  ago,  the  lad  had  had  disease  of  one  testis,  which  had  been 
removed,  and  Dr.  McGill  states  that  on  section  it  seemed  to  be  in  a 
sloughing  condition.  He  had,  however,  bruised  himself  on  his 
bicycle.  This  fact  was  of  very  special  importance  in  the  history  of 
the  case,  as  it  seemed  most  likely  that  the  liver  condition  was  asso- 
ciated with  the  disease  of  the  testis,  and  from  the  length  of  time 
which  had  elapsed  since  the  removal  of  the  organ  it  rather  favored 
the  idea  that  the  condition  was  neoplasm.  I  must  say,  however, 
that  the  physical  examination  of  the  two  tumor  masses  in  the 
epigastrium  led  us  all  to  expect  fluid,  and  I  should  unhesitatingly 
have  put  in  an  aspirating  needle  with  the  exjpectation  of  withdraw- 
ing either  pus  or  a  clear  fluid. 

Dr.  Tiffany  made  an  incision  four  inches  in  length  over  the 
lower  tumor  and  exposed  a  large  hemispherical  swelling  in  the  left 
lobe  of  the  liver.  There  were  no  adhesions  ;  the  superficial  sub- 
stance had  a  natural  reddish-brown  color,  and  puncture  with  the 
hypodermic  needle  withdrew  nothing  but  blood.  Dr.  Tiffany  in- 
serted his  fixigers  and  examined  the  upper  mass,  which  was  a 
second  soft  enlargement,  and  on  the  under  surface  of  the  liver 
there  were  several  others,  leaving  no  question  that  there  was  a 
multiple  new  growth  in  the  organ.  The  patient  was  extremely 
weak  after  the  operation,  but  rallied  for  a  few  days. 

In  this  case,  as  in  one  or  two  otliers  wli  icli  I  can  call  to 
mind,  I  have  been  led  astray  by  the  deceptive,  semi-fluctu- 
ating character  of  liver  tumors. 

Primary  new  growths  in  the  liver  in  young  men  are,  of 
course,  extremely  rare,  and,  taking  all  the  circumstances 
of  the  case  into  account,  it  is  more  rational  to  suppose  that 

< ■ — ■ ' ' — ■ -— ■ — — rtr- 

*  Americcm  Journal  of  the  Medical  ScienceSy  October,  1882. 


98  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

the  lad  had  a  new  growth  in  the  testis,  which  was  bruised 
by  the  bicycle,  and  it  was  this  in  an  inflamed  condition 
which  Dr.  McGill  removed  in  May,  1891. 

The  presence  of  tumor  masses  on  the  liver  is,  then,  one 
of  the  most  distinctive  features  of  cancer  of  the  organ, 
more  particularly  of  the  secondary  form,  which  constitutes 
so  large  a  proportion  of  all  cases.  The  primary  lesion  is 
to  be  looked  for  in  the  stomach,  intestines,  urogenital 
organs,  or  the  breast.  The  new  growths  are  scattered  dif- 
fusely with  large  nodular  masses  on  the  surface  or  at 
the  edge.  The  rounded  margin  and  cup-shaped  depression 
are  pathognomonic  of  these  secondary  cancerous  nodules. 
The  irregular  syphilitic  liver  could  alone  be  confounded 
with  it,  but  in  this  condition  there  is  rarely  progressive 
enlargement  of  the  organ,  and  the  general  features  of  the 
case  are  those  of  cirrhosis  of  the  liver. 

Tumor  masses,  as  a  rule,  are  absent  in  the  primary  can- 
cer of  the  organ  and  in  the  form  known  as  cancer  with 
cirrhosis,  in  both  of  which  conditions  the  organ  may  be 
of  normal  size,  or  even  somewhat  reduced.  Lastly,  large, 
rapidly  growing  encephaloid  or  sarcomatous  growths  may, 
as  in  Case  XXXV,  produce  prominent  tumors  evident 
beneath  the  skin  in  the  epigastric  region,  and  which  may 
apparently  fluctuate,  due  either  to  the  very  soft  nature  of 
the  neoplasm,  or  in  some  instances  to  haemorrhage. 


LECTURE  IV. 

TUMORS   OF   THE   GALL  BLADDER.* 

The  gall  bladder  may  be  dilated  or  its  walls  infiltrated 
■with  a  new  growth.  In  a  large  proportion  of  all  cases 
these  conditions  are  associated  with  gallstones.  Of  six 
cases  in  which  the  gall  bladder  presented  either  tumor  or 
enlargement,  three  were  due  to  gallstones,  one  to  compres- 
sion of  the  common  duct  by  malignant  disease,  and  in  two 
the  walls  were  infiltrated  with  cancer. 

(a)  Dilated  Gall  Bladder. — The  organ  may  form  a 
small,  firm,  rounded  projection  beneath  the  edge  of  the 
liver,  a  pyriform  tumor  of  varying  size  and  freely  mov- 
able, in  exceptional  cases  a  very  large  tumor  reaching  to 
the  pelvis,  or,  indeed,  as  in  a  case  reported  by  Tait,  a  huge 
cyst  occupying  the  greater  part  of  the  abdominal  cavity. 
The  usual  causes  of  dilatation  are  blocking  the  ducts  with 
calculi  and  compression  of  them  by  new  growths.  The 
greatest  dilatation  is  associated  with  obstruction  of  the 
cystic  duct.  Permanent  blocking  of  the  common  duct 
does  not  necessarily  lead  to  very  great  distention  of  the 
gall  bladder.  The  contents  of  the  dilated  organ  may  be  a 
clear  mucoid  fluid  when  the  obstruction  is  in  the  cystic 
duct  and  very  prolonged ;  bile  most  frequently  when  the 
obstruction  is  in  the  common  duct ;  pus  or  a  purif  orm  bile- 
stained  fluid  when  suppuration  has  occurred,  and  an  albu- 
minous or  bloody  fluid  in  cancer  of  the  walls.     I  will  first 

*  Delivered  December  6th. 
11  99 


100  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

read  to  you  the  cases  in  wliicli  the  gall  bladder  formed  a 
prominent  tumor.  Two  of  these  were  associated  with  gall- 
stones and  one  with  obstruction  of  the  common  duct  by  can- 
cer. The  diagnosis,  which  seemed  perfectly  clear,  was  con- 
firmed in  one  case  by  operation  and  in  another  by  autopsy. 
But  before  I  do  so  let  me  call  your  attention  to  two  mono- 
graphs, the  most  important  contributions  to  the  literature 
of  cholelithiasis  which  have  been  made  for  some  years. 
Professor  Naunyn's  work,  Klinik  der  Cholelithiasis,  deals 
particularly  with  aetiology  and  symptomatology,  while 
that  of  Professor  Riedel,  Erfahrungen  uber  die  Oallen- 
steinkranTcheit,  mit  und  ohne  Icterus,  is  of  very  special 
value  to  workers  in  clinical  medicine,  and  illustrates  in  an 
interesting  way  the  close  interdependence  of  medicine  and 
surgery.  His  careful  study  of  an  extensive  series  of  cases 
upon  which  he  had  operated  enlarges  in  certain  directions 
our  knowledge  of  the  symptomatology  of  gallstones,  more 
particularly  of  the  cases  without  jaundice. 

Case  XXXYI.  Gall  Bladder  forming  a  Visible  Tumor;  Oper- 
ation; jRecouert/.— Elizabeth  D.,  Lonaconing,  Alleghany  County, 
Md.,  aged  sixty-two  years,  seen  with  Dr.  Kelly.  She  had  been 
married  thirty-eight  years;  had  six  children;  three  miscarriages; 
labors  non-instrumental,  but  tedious. 

Family  history  good.  Has  always  been  well  until  the  present 
trouble.  In  December,  1891,  she  fell  against  the  curbstone  and 
struck  the  right  side.  At  the  time  she  felt  very  little  pain,  but  re- 
marked that  she  had  had  a  great  "shaking  up."  Some  time  in 
January,  she  does  not  know  exactly  when,  she  noticed  a  lump  in 
the  abdomen  which  changed  in  position  as  she  moved  in  bed.  It 
has  not,  she  says,  got  any  larger  since  January.  Five  weeks  ago 
she  one  night  became  jaundiced.  She  is  positive  that  the  skin  was 
clear  one  day  and  the  next  morning  pretty  deeply  jaundiced.  The 
stools  were  clay-colored,  and  remain  so.  Since  then  the  bowels 
have  been  at  times  loose,  sometimes  three  or  four  in  a  day.  The 
urine  became  high-colored ;  the  skin  has  been  itchy,  and  the  pulse 


TUMORS  OF  THE  GALL  BLADDER. 


101 


rate  very  slow.     She  has  lost  somewhat  in  weight ;  she  has  had  no 
chills,  no  fever,  and  no  sweating. 

Present  Condition. — Large,  well-nourished  woman;  the  skin  of 
an  orange-green  color;  tongue  clean;  pulse,  33;  temperature  nor- 
mal. The  abdomen  is  enlarged  and  flabby.  On  the  right  side, 
midway  between  the  costal  margin  and  Poupart's  ligament,  there  is 
to  be  seen  a  hemispherical  prominence,  which  moves  up  and  down 
with  respiration.  On  palpation  the  abdomen  is  everywhere  soft, 
not  painful.  The  liver  can  be  felt  in  the  epigastric,  right  umbili- 
cal, and  right  hypochondriac  regions, 
firm  and  resistant,  and  in  the  middle 
line  the  margin  can  be  felt  about  two 
fingers'  breadth  above  the  navel.  In 
the  right  parasternal  line  a  distinct 
notch  can  be  felt,  the  separation  prob- 
ably between  the  right  and  left  lobes. 
In  the  nipple  line  the  edge  reaches  to 
the  level  of  the  navel  and  in  the  an- 
terior axillary  line  nearly  to  the  level 
of  the  anterior  superior  spine.  The 
prominent  mass  which  is  seen  with 
such  distinctness  can  be  felt  a  hand's 
breadth  below  the  liver  margin ;  it  is 
smooth,  rounded,  resistant,  and  as  the 
fingers  are  pushed  beneath  it  there  is 
the  impression  of  a  globular  body.  It 
can  be  freely  moved  from  side  to  side, 
and  changes  in  position  as  she  turns  to  the  left.  The  dotted  line 
in  the  diagram  indicates  the  position  when  she  rolled  over  on  the 
left  side  ;  the  fundus  of  the  gall  bladder  then  almost  reaches  the 
middle  line. 

The  surface  of  the  liver  is  smooth.  There  are  no  nodules.  On 
deep  inspiration  the  spleen  can  not  be  felt ;  there  are  no  glandular 
enlargements.  There  is  a  systolic  murmur  at  the  apex  of  the  heart, 
but  the  sounds  are  clear  at  the  base.  The  stools  are  clay-colored ; 
the  urine  contains  much  bile  pigment. 

November  7th. — This  morning  Dr.  Kelly  made  an  incision  fifteen 
centimetres  long  over  the  tumor.    On  opening  the  peritoneal  cavity 


Fig.  30.— Showing:  the  position  of 
the  gall  bladder  in  Case  XXXVI. 


102  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

the  liver  looked  of  a  dark  greenish-brown  color.  Projecting  be- 
neath the  edge  of  the  right  lobe  for  a  distance  of  about  five  centi- 
metres was  the  rounded  end  of  a  dilated  gall  bladder.  The  liver 
substance  above  it  was  considerably  atrophied.  There  were  no  ad- 
hesions. The  chief  bulk  of  the  dilatation  was  beneath  the  liver, 
and  the  dilatation  was  much  greater  than  indicated  by  the  portion 
which  could  be  felt  projecting  beyond  the  edge.  One  hundred  and 
fifty  cubic  centimetres  of  turbid,  grayish  pus  were  removed  with 
the  aspirator.  Calculi  could  be  felt  in  the  cystic  duct  and  at  the 
first  portion  of  the  common  duct.  After  aspiration  the  gall  blad- 
der was  carefully  stitched  to  the  external  wound  and  incised  and 
a  large  gall  stone  removed  weighing  thirty-eight  grammes.  The 
stone  occupied  the  cystic  duct  and  projected  into  the  common 
duct. 

The  points  of  interest  in  connection  with  this  case  are, 
in  the  first  place,  the  easy  diagnosis  of  dilated  gall  bladder 
on  account  of  the  position  and  character  of  the  tumor.  It 
seemed  most  likely,  too,  that  the  dilatation  and  the  jaun- 
dice were  due  to  gallstones,  though  she  had  never  had 
attacks  of  biliary  colic.  In  all  probability  the  cystic  duct 
was  blocked  by  the  large  stone  as  early  as  December, 
when  she  fell  against  the  curbstone ;  she  is  positive  that 
the  lump  on  the  right  side  has  been  present  ever  since 
that  time.  The  sudden  onset  of  the  jaundice  five  weeks 
ago  was  connected  doubtless  either  with  the  moving  of 
the  stone  into  the  common  duct  or  the  extension  of  in- 
flammation from  the  cystic  duct  to  it ;  most  probably  the 
former. 

A  second  point  of  great  interest  in  the  case  is  the  ex- 
istence of  an  empyema  of  the  gall  bladder  without  chills 
or  fever.  In  all  probability  the  suppurative  process  was 
confined  to  the  gall  bladder  and  had  not  extended  to  the 
general  bile  passages,  associated  with  which,  so  far  as  I 
know,  there  is  invariably  fever  of  a  septic  type. 

The  patient  did  very  well.  Much  bile-stained  material 
escaped  from  the  wound,  the  jaundice  became  distinctly 


TUMORS  OF  THE  GALL  BLADDER.  103 

lighter,  and  bile  appeared  in  the  faeces.  By  the  14th  of 
November  the  skin  was  much  less  yellow,  the  urine  lighter 
in  color,  and  the  itching  of  the  skin  had  entirely  ceased. 
She  improved  rapidly,  sat  up  by  November  21st,  and  was 
discharged  on  December  14,  1892. 

Case  XXVII.  Attacks  of  Gallstone  Colic;  Tumor  of  Gall 
Bladder. — Miss  S.,  aged  about  forty -eight  yeai*s,  seen  with  Dr. 
Ames,  June  16,  1893,  complaining  of  swelling  and  pain  in  the 
abdomen.  Patient  has  been  delicate  from  childhood,  and  has 
been  for  years  a  chronic  invalid. 

When  about  ten  years  of  age  she  had  a  severe  illness  and  for 
some  time  could  take  no  nourishment  without  severe  abdominal 
pain.  Dr.  Buckler  thought  that  it  was  possibly  ulceration  of  the 
stomach.  When  twenty  years  of  age  she  had  a  similar  illness — 
evidently  protracted,  painful  dyspepsia.  When  thirty-five  years 
old  she  had  a  severe  attack  of  liver  colic,  in  which  she  changed 
color  and  was  slightly  jaundiced.  She  has  had  since  that  time 
many  attacks  of  pain,  particularly  at  night,  after  a  very  trying  or 
exhausting  day.  At  forty-three  the  menopause  began,  following 
which  she  had  a  nervous  breakdown  and  went  to  Italy,  and  for  a 
couple  of  years  she  had  a  great  deal  of  intestinal  trouble.  After 
returning,  on  September  6th  of  last  year,  she  had  a  very  severe 
attack  of  colic  and  was  extremely  weak.  These  attacks  of  colic 
have  occurred  throughout  the  winter  and  the  last  one  she  had  was 
only  a  few  weeks  ago. 

Present  Condition.  —  Small-framed  woman,  looks  ill,  very 
anaemic  and  sallow  ;  no  definite  jaundice  ;  no  special  emaciation. 
Pulse  92 ;  tension  a  little  increased. 

Abdomen  flat,  natural-looldng.  Palpation  is  everywhere  nega- 
tive until  one  reaches  the  liver  region.  Here  inside  the  nipple  line 
there  is  a  definite  rotmded  projection,  the  outlines  of  which  can 
be  readily  determined,  particixlarly  below  and  to  the  left.  It  pro- 
jects as  a  somewhat  conical  mass  and  is  rounded  at  the  right  bor- 
der. It  is  a  little  painful  on  deep  pressure.  The  fingers  can  not 
be  inserted  definitely  beneath  it,  but  on  either  side  the  edge  of  the 
liver  is  distinct;  as  she  draws  a  deep  breath  the  fingers  seem  to 
pass  over  a  prominence  into  a  depression  on  the  surface  of  the  liver 


104: 


THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 


just  at  the  level  of  the  costal  margin.  During  the  attacks  the  pro- 
jection, as  she  calls  it,  forms  a  prominent  tumor  which  can  be  seen 
beneath  the  skin  and  is  then  exquisitely  sensitive.  The  liver  dull- 
ness extends  to  the  upper  border  of 
the  sixth  rib.  The  right  kidney  is 
distinctly  palpable  and  descends  be- 
low the  edge  of  the  liver,  from  which 
it  can  be  readily  separated. 

At  a  subsequent  examination  the 
tumor  was  not  nearly  so  large,  and 
she  insists  that  it  is  extremely  va- 
riable in  size.  Whenever  the  colic  is 
severe  the  tumor  becomes  very  much 
more  prominent,  a  point  confirmed 
repeatedly  by  Dr.  Ames.  She  is  ex- 
cessively anaemic,  and  though  anxious 
for  an  operation,  it  was  thought  best 
to  postpone  it  until  the  condition  of 
her  blood  was  more  satisfactory. 

Additional  Note.  —  The  tumor 
mass  in  the  epigastrium  developed 
considerably  and  became  very  much  firmer,  reaching  almost  to 
the  level  of  the  navel.  The  patient  herself  said  that  it  had  un- 
dergone a  change,  and  she  had  a  good  deal  of  pain  at  intervals. 
She  was  very  urgent  that  an  operation  should  be  performed,  and, 
as  her  general  condition  seemed  fairly  good.  Dr.  TifiPany,  on  Janu- 
ary 9th,  made  an  exploratory  incision.  The  gall  bladder  projected 
between  two  and  three  inches  below  the  margin  of  the  liver,  A 
coil  of  the  small  intestine,  and  also  the  transverse  colon,  were 
firmly  adherent  to  it,  and  over  its  surface  there  was  a  defijaite  vas- 
cular membrane.  There  were  numerous  adhesions  between  the 
upper  surface  of  the  liver  and  the  diaphragm.  The  gall  bladder 
felt  firm,  and  at  its  fundus  there  was  a  nodular  mass.  When  it 
was  opened  a  bile-stained  mucus  exuded  and  the  whole  organ  ap- 
peared filled  with  a  semisolid,  friable,  grayish -yellow  mass.  Frag- 
ments removed  with  a  curette,  particularly  the  scrapings  of  the 
wall,  had  a  grayish-white  appearance,  and  looked  like  a  new 
growth.     On  microscopical  examination  they  consisted  of  large, 


Pro.  31.— Showing  the  position  of 
the  gall  bladder  and  outline  of 
the  right  kidney. 


TUMORS  OP  THE  GALL  BLADDER.  105 

irregular  cells,  many  of  which,  were  in  a  state  of  fatty  degenera- 
tion. After  doing  well  for  three  or  four  days  the  patient  began  to 
complain  very  much  of  pain  in  the  lower  part  of  the  abdomen. 
There  was  no  swellLag,  and  until  the  evening  of  the  14th  there  was 
no  fever.  On  the  15th  the  pulse  was  more  rapid,  and  she  seemed 
very  much  weaker.  She  was  worried  about  not  having  had  an 
action  of  the  bowels,  and  was  a  good  deal  exhausted  in  an  attempt 
to  get  them  relieved.  About  one  o'clock  she  became  feebler,  gradu- 
ally sank  into  a  condition  of  unconsciousness,  and  died  about  5.30 
in  the  afternoon. 

Autopsy^  Jan.  16. — The  wound  of  the  skin  and  the  incision  in 
the  gall  bladder  had  both  united  well.  After  turning  back  the  skin 
flaps,  the  intestines  were  found  to  cover  the  gall  bladder  every- 
where, except  at  a  small  area  just  below  the  liver  margin  in  the 
nipple  line.  The  portion  of  the  right  lobe  of  the  liver  adjacent  to 
it  was  considerably  elongated,  and  consisted  of  a  grayish-white 
atrophic  tissue.  The  stomach  was  distended  and  the  duodenum 
was  pushed  forward  and  much  dilated  with  gas.  It  was  opened  in 
situ.,  and  its  posterior  wall  found  to  be  in  close  contact  with  the 
gall  bladder.  The  bile  papilla,  which  was  in  the  transverse  portion 
of  the  duodenum,  was  not  occluded.  After  dissecting  off  the  duo- 
denum the  tumor  beneath  it  was  seen  to  be  the  greatly  distended 
gall  bladder,  somewhat  larger  than  a  closed  fist.  It  was  deeply 
placed,  lifted  the  head  of  the  pancreas  and  the  duodenum,  as 
already  mentioned,  and  was  in  contact  with  the  right  side  of  the 
vertebral  column.  It  was  readily  and  freely  lifted  from  its  bed, 
and  then  was  seen  to  project  about  eight  centimetres  below  the 
liver  margin.  The  transverse  colon  was  adherent  to  it,  and  just 
at  the  point  of  their  union  there  was  a  nodule  of  new  growth  of 
the  size  of  an  English  walnut.  On  incising  the  gall  bladder,  a 
small  quantity  of  turbid  bUe  exuded,  but  the  entire  viscus  was  occu- 
pied by  a  globular  new  growth,  which  was  everywhere  free,  except 
at  the  upper  wall,  where  it  was  densely  adherent  and  had  grown 
into  the  substance  of  the  right  lobe.  It  did  not  extend  to  the  neck 
of  the  gall  bladder,  and  the  orifice  of  the  cystic  duct  was  free. 

On  section,  the  mass  consisted  of  a  fresh,  grayish  neoplasm,  on 
its  surface  much  bile-stained.  There  were  six  or  eight  small,  black 
irregular  gallstones.    There  were  no  secondary  nodules  in  the  liver. 


106  THE  DIAGNOSIS  OP  ABDOMINAL  TUMORS. 

The  common  duct  was  free.  The  stomach  and  intestines  looked 
normal.  There  was  a  small  cyst  of  the  left  parovarium,  which  was 
united  to  the  rectum  by  old,  firm  adhesions. 

Case  XXXVIII.  Enlarged  Gall  Bladder;  Jaundice;  Cancer 
of  the  Head  of  the  Pancreas. — Mr.  M.,  aged  fifty-one  years,  seen 
April  26,  1893,  with  Dr.  W.  W.  Johnston.  The  patient  is  a  large 
man,  very  active  in  business,  and  with  an  excellent  family  and  per- 
sonal history.  He  had  a  slight  attack  of  jaundice  during  the  civil 
war.  Has  not  been  a  heavy  drinker.  Was  well  and  strong  until 
toward  the  end  of  last  year.  He  had  a  mental  shock  and  worry  in 
October  which  distressed  and  disturbed  him  a  good  deal,  and  he 
had  dyspepsia  on  one  or  two  occasions  before  Christmas.  Early  in 
January  he  had  a  very  severe  attack  with  vomiting,  and  then  be- 
gan to  lose  in  weight  and  had  uneasy  sensations  in  the  epigastric 
region,  but  no  sharp,  acute  pain.  About  the  middle  of  January  he 
noticed  that  he  was  yellow  in  color,  and  the  jaundice,  increasing 
in  intensity,  has  been  permanent.  The  stools  have  been  clay-col- 
ored; the  urine  very  much  bile-tinged.  He  has  had  no  itching, 
nor  has  the  pulse  ever  been  slow.  He  has  lost  progressively  in 
weight,  thinks  as  much  as  forty  or  fifty  pounds,  and  has  become 
very  weak,  though  he  has  kept  up  and  about,  and  until  two  weeks 
ago  has  attended  to  his  business. 

Present  Condition. — Intense  olive-green  jaundice  ;  moderate 
emaciation;  pulse,  82;  fair  volume;  moderate  tension;  vessel  not 
sclerosed. 

Abdomen  prominent,  and  percussion  and  palpation  demon- 
strate the  existence  of  moderate  ascites,  which,  Dr.  Johnston  says, 
has  not  materially  changed  for  several  weeks.  On  palpation,  no 
pain,  nothing  abnormal  to  be  felt  until  toward  the  right  costal 
margin,  below  which  the  liver  extends  for  about  an  inch  and  a 
half  in  the  parasternal  line.  In  the  anterior  axillary  line,  about 
two  inches  in  front  of  the  cartilage  of  the  tenth  rib,  there  is  a  firm, 
rounded,  nodular  body  the  size  of  the  top  of  a  lemon,  which  is  at- 
tached to  the  liver  and  projects  definitely  beyond  its  edge.  It 
feels  like  a  distended  gall  bladder,  but  it  is  unusually  hard,  firm, 
and  inelastic,  and  it  is  not  movable  from  side  to  side.  On  deep  in- 
spiration, the  surface  of  the  liver  above  it  can  be  felt  to  be  dis- 
tinctly depressed.     In  the  parasternal  line  the  edge  of  the  liver  is 


TUMORS  OF   THE  GALL  BLADDER.  107 

irregular,  and  there  appear  to  be  one  or  two  nodules.  In  tlie  mid- 
dle line,  on  deep  inspiration,  the  siirface  of  the  left  lobe  also  ap- 
pears rough  and  irregular.  The  spleen  is  not  palpable.  The 
stomach  does  not  appear  to  be  dilated.  Examination  of  the  tho- 
racic organs  is  negative. 

Patient  died  May  7,  1893.  The  autopsy  showed  cancer  of  the 
pancreas,  with  secondary  nodules  in  the  liver.  The  gall  bladder 
was  greatly  distended  and  projected  beyond  the  edge  of  the  liver, 
and  formed  the  tumor  which  had  been  so  plainly  to  be  felt  dur- 
ing life,  measured  about  six  inches  in  length  and  about  three 
inches  in  diameter,  and  was  full  of  a  light-greenish  fluid.  The 
walls  were  not  indurated. 

In  the  diagnosis  of  the  tumor  caused  by  dilatation  of 
the  gall  bladder  there  are  details  to  which  I  may  here 
refer.  The  patient  should  be  recumbent,  in  a  perfectly 
easy  posture,  with  the  abdominal  walls  as  much  relaxed  as 
possible.  Sometimes,  as  in  Case  XXXVI,  a  prominent 
tumor  is  at  once  visible,  descending  with  inspiration,  or 
there  may  be  a  swelling  of  considerable  size  in  the  right 
half  of  the  abdomen.  More  frequently,  however,  inspec- 
tion is  negative,  and  the  facts  must  be  elicited  by  careful 
palpation.  The  facility  with  which  this  procedure  can  be 
carried  out  depends  upon  the  degree  of  rigidity  of  the  ab- 
dominal walls,  and  a  thorough  examination  may  be  impos- 
sible without  anaesthetizing  the  patient.  Bimanual  palpa- 
tion is  the  most  satisfactory.  Sitting  by  the  side  of  the 
patient,  the  left  hand  beneath  the  lower  ribs,  with  the  right 
upon  the  abdomen,  a  little  below  the  costal  margin  in  the 
nipple  line,  gentle  palpation  with  the  pads  of  the  fingers 
is  first  made  during  quiet  breathing.  The  patient  is  then 
asked  to  draw  a  deep  breath,  and  gentle  but  firm  palpation 
is  repeated,  the  fingers  of  the  right  hand  following  the  re- 
ceding abdominal  walls.  The  anterior  edge  of  a  normal 
liver  can  in  this  way  be  readily  felt,  and  any  marked  pro- 
jection of  the  gall  bladder  detected.  On  the  whole,  I 
12 


108  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

think  you  will  find  it  more  satisfactory  to  use  the  fingers  of 
the  right  hand  for  palpation,  but  it  is  possible  also  to  use 
the  thumb  of  the  left  hand  in  the  method  described  by 
Gl^nard,  his  procede  du  pouce.  The  left  hand  grasps  the 
right  flank  with  the  fingers  behind.  With  the  thumb, 
which  is  then  free,  the  edge  and  surface  of  the  anterior 
part  of  the  right  lobe  of  the  liver  can  be  readily  felt,  as  the 
organ  descends  during  inspiration.  The  facility  with 
which  this  procedure  can  be  carried  out  depends  some- 
what upon  the  length  and  mobility  of  the  thumb. 

Situation  and  General  Characters. — The  position  varies 
with  the  size  of  the  tumor  and  the  existence  of  enlarge- 
ment of  the  liver.  Moderately  distended  in  a  liver  of 
normal  size,  the  gall  bladder  may  be  felt  projecting  be- 
neath the  costal  margin  opposite  the  end  of  the  tenth  cos- 
tal cartilage.  It  is  superficial,  appearing  to  lie  immediately 
beneath  the  abdominal  wall.  The  long  axis  may  be  par- 
allel with  the  nipple  line.  More  frequently,  however,  the 
direction  is  somewhat  to  the  left,  as  indicated  by  Fig.  31. 
The  tumor  is  usually  to  the  right  of  the  parasternal  line, 
but  it  may  be  directly  in  or  even  to  the  right  of  the  nipple 
line,  while  in  other  instances  it  may  be  chiefly  to  the  left 
of  the  parasternal  line.  The  fingers  may  be  placed  di- 
rectly beneath  it,  and  the  sensation  given  is  that  of  a 
smooth,  rounded  body,  larger  at  the  lower  end  than  above 
—that  is,  pear-shaped.  While  the  outlines  below  are 
usually  readily  defined,  toward  the  liver  they  are  obscure, 
and  no  definite  edge  can  be  felt  above  the  tumor.  This 
is  a  point  of  importance  in  the  differentiation  of  floating 
kidney.  Sometimes  the  tumor  appears  to  be  turned  for- 
ward on  its  axis,  like  a  gourd,  and  a  groove  may  be  felt 
separating  it  from  the  liver.  As  a  rule,  palpation  is  not 
accompanied  with  much  pain.  The  sensation  conveyed  to 
the  finger  is  usually  that  of  a  tense,  firm,  elastic  body. 
This  is  not  always  the  case,  for  an  enlarged  gall  bladder 


TUMORS  OF  THE  GALL  BLADDER.  109 

may  be  extremely  flabby  and  soft,  and  is  then  diflicult  to 
feel.  On  the  other  hand,  it  is  to  be  remembered  that  in 
long-standing  cases  of  cholelithiasis  there  may  be  complete 
calcification  of  the  walls  of  the  gall  bladder,  forming  a 
tumor  of  stony  consistence.  The  size  of  the  tumor  pro- 
jecting beyond  the  liver  margin  is  some  measure  of  the 
degree  of  distention  of  the  gall  bladder,  particularly  when 
the  dilatation  is  due  to  plugging  of  the  cystic  duct.  When 
the  common  duct  is  obstructed  there  may  be  great  dilata- 
tion of  the  gall  bladder  and  ducts  with  only  a  slight 
tumor  projecting  beyond  the  costal  margin.  I  have  re- 
ported a  case,  operated  upon  by  the  late  Dr.  Agnew,  in 
which  the  fundus  of  the  gall  bladder  projected  only  2'5 
centimetres,  but  on  lifting  up  the  liver  it  was  seen  that  the 
distention  was  chiefly  beneath  the  margin,  and  eighteen 
ounces  of  bile  were  removed  by  aspiration.  While  these 
statements  hold  for  moderate  dilatation  of  the  gall  blad- 
der, you  must  remember  that  there  are  instances  on  record 
in  which  the  tumor  is  exceptionally  large,  extending  to 
the  pelvis,  occupying  the  entire  right  side,  or  even  filling 
the  abdominal  cavity  like  a  large  ovarian  cyst. 

You  will  have  noticed  in  the  reading  of  the  report  of 
Case  XXXVI  that  the  tumor  was  extremely  mobile  and 
that  the  patient  herself  noticed  its  variability,  and,  pro- 
jecting as  it  did  so  plainly,  the  alterations  in  position 
could  be  seen.  The  mobility  during  respiration  is  also 
well  marked  and  it  may  be  seen  to  descend  with  inspira- 
tion. On  palpation  the  tumor  may  be  moved  freely  from 
side  to  side.  On  the  deepest  inspiration,  however,  it  can 
not  be  grasped  and  held  in  position  as  is  possible  with  an 
extremely  mobile  kidney. 

Nature  of  the  Contents. — In  a  doubtful  case  of  tumor 
projecting  below  the  right  costal  border  aspiration  may 
be  practiced,  using  a  fine  needle  and  exercising  caution 
that  the  bowel  does  not  lie  between  the  tumor  and  the 


110  THE  DIAGNOSIS  OP  ABDOMINAL  TUMORS. 

abdominal  wall.  The  contents  of  a  dilated  gall  bladder 
are  either  clear  mucus,  which  is  most  common  in  pro- 
longed obstruction  of  the  cystic  duct ;  bile,  when  the  com- 
mon duct  is  blocked,  though  when  occluded  for  a  pro- 
longed period  the  entire  bile  passages,  including  the  gall 
bladder,  may  be  filled  with  a  thin  mucus.  Pus  is  met 
with  frequently,  usually  general  symptoms  indicating  that 
suppuration  has  occurred ;  and,  lastly,  blood  may  be  pres- 
ent in  cases  of  neoplasm  of  the  gall  bladder.  In  acute 
phlegmonous  inflammation  due  to  calculus,  the  gall 
bladder  may  contain  a  dirty,  brownish-red,  ill-smelling 
fluid. 

From  growths  at  the  pylorus  and  in  the  colon,  which 
may  occupy  a  similar  position,  the  gall-bladder  tumor  is,  as 
a  rule,  readily  distinguished,  both  by  the  differences  in  the 
symptoms,  and  particularly  by  the  systematic  local  exam- 
ination, using  also  the  inflation  of  the  stomach  and  intes- 
tine. To  two  conditions  I  would,  however,  call  your  atten- 
tion. In  stout  persons  and  when  the  abdominal  walls  are 
unusually  tense,  movable  kidney  on  the  right  side  may 
be  mistaken  for  an  enlarged  gall  bladder.  Only,  however, 
when  the  kidney  is  very  movable  does  it  descend  so  low 
and  so  far  to  the  left  that  this  mistake  could  occur.  It 
does  sometimes,  however,  emerge  beneath  the  liver  margin 
as  a  rounded  tumor  in  a  most  deceptive  manner.  With 
the  patient  recumbent  and  the  kidney  in  its  natural  posi- 
tion, no  tumor  is  evident ;  but  on  change  of  position  (turn- 
ing to  left)  or  on  deep  inspiration  it  then  appears.  A  mov- 
able kidney  on  the  deepest  inspiration,  with  the  fingers 
placed  above  it,  can  be  held  down  and  prevented  from 
returning  during  the  expiratory  movement.  A  gall-blad- 
der tumor  rises  and  falls  with  the  expiratory  movements, 
and  can  not  be  held  down  during  expiration.  Again, 
above  the  rounded  surface  of  the  kidney,  the  sharp 
margin  of  the  liver  may  be  felt  with  great  distinctness. 


TUMORS  OF  THE  GALL  BLADDER. 


Ill 


whereas  in  gall-bladder  tumor  the  upper  limit  is  not  to  be 
defined,  and  there  is  no  sharp  edge  above  it. 

An  interesting  anatomical  condition  o:^  the  liver  which 
you  must  learn  to  recognize  has  been  referred  to — par- 
ticularly by  Professor  Riedel — namely,  a  tongue-shaped 
process  of  the  anterior  margin.  A  knowledge  of  its  ex- 
istence may  save  you  from  error.  I  show  you  here  the 
outline  as  given  by  him  in  one  of  his  cases  (Fig.  32).  He 
believes  that  this  extension  is  seen  particularly  in  women 
whose  livers  have  suffered  from  the  effects  of  lacing,  but 
it  is  directly  caused  by  traction,  the  gradually  distending 
gall  bladder  elongating  the  anterior  margin.  In  twelve  of 
the  cases  upon  which  Riedel  operated  this  tongue-like 
process  was  present  ;  in  nine  in- 
stances the  gall  bladder  was  pal- 
pable either  at  the  median  or  un- 
der margin  of  the  process.  In 
Case  XXXVIII  I  believe  this  pro- 
cess is  present.  It  is  not  always, 
however,  associated  with  dilated 
gall  bladder,  and  I  have  seen  very 
curious  elongations  of  the  anterior 
margin  of  the  right  lobe  in  per- 
fectly normal  livers,  and  in  several 
instances  of  the  posterior  margin 
of  the  left  lobe.  It  is  important 
to  recognize  the  existence  of  this 
process  as  it  may  form  a  very 
definite  mass  in  the  right  flank. 
A  very  interesting  instance  of  it 
was  referred  to  me  by  Dr.  Weir 
Mitchell  two  years  ago.  An  extremely  nervous  woman, 
aged  about  fifty-six  years,  had  had  for  several  years 
symptoms  of  neurasthenia,  pains  in  the  abdomen,  and 
ill-defined   manifestations,  for  which  she  had  sought  re- 


Fio.  32.— The  tongue-shaped  ex- 
tension of  the  anterior  margin 
of  the  right  lobe,  with  the  gall 
bladder  projecting  below  it. 
(Riedel.) 


112  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

lief  in  many  quarters.  In  his  note  to  me  Dr.  Mitchell 
stated  that  there  was  a  tumor  of  a  doubtful  nature  in 
the  right  flank.  I  saw  the  patient  with  her  relative  Dr. 
Tilghman.  The  only  interest  in  the  case  is  in  the  examina- 
tion of  the  abdomen.  Just  beneath  the  right  costal  mar- 
gin, extending  toward  the  anterior  superior  spine,  was  an 
elongated  mass  with  very  ill-defined  borders.  The  fingers 
could  not  be  inserted  beneath  it,  nor  was  there  a  definite 
edge  palpable.  It  was  tender  on  pressure,  not  movable  in 
a  lateral  direction,  but  with  the  fingers  deep  in  the  flank 
behind  it  could  be  tilted  forward.  It  did  not  seem  to  be 
continuous  with  the  liver,  the  dullness  of  which  terminated 
just  below  the  costal  margin.  It  descended  somewhat  with 
the  respiratory  movements.  The  right  kidney  was  not 
palpable.  Altogether  I  was  puzzled  by  the  condition,  and 
could  not  give  a  positive  opinion  as  to  the  nature  of  the 
trouble.  She  had  a  good  deal  of  abdominal  pain  and  dis- 
tress, most  of  which  I  thought  was  associated  with  nervous 
dyspepsia.  As  there  bad  been  some  uterine  trouble  I  sug- 
gested that  the  pelvic  organs  should  be  examined.  Subse- 
quently, she  came  under  the  care  of  my  colleague.  Dr. 
Kelly,  who  at  once  discovered  the  tumor  in  the  abdomen 
and,  with  the  advantage  pertaining  to  surgery,  he  very 
quickly  determined  by  laparotomy  the  nature  of  the  tumor 
— namely,  an  elongation  from  the  right  lobe  of  the  liver. 
He  writes :  "  There  was  no  visceral  trouble,  excepting  the 
enormously  elongated  thiuned-out  lobe  of  the  liver,  which 
extended  down  on  the  right  side  at  least  four  inches  below 
the  normal  position,  and  seemed  to  be  an  elongation  of 
the  anterior  margin.  The  gall  bladder  was  not  enlarged."  * 
(&)  Cases  with  Ill-defined  Nodular  Tumor  at 
Liver  Edge,  supposed  to  be  Gall  Bladder. — While  the 

*  Those  interested  in  the  subject  may  consult  with  advantage  Hertz's 
recent  work,  Abnormitdten  in  der  Lage  tind  Form  der  Bauchorgane  bei  dem 
erwachsenen  Weibe,  eine  Folge  des  Schnuren  und  Hangebauches. 


TUMORS  OF  THE  GALL  BLADDER.  113 

presence  of  a  well-defined  tumor  is  of  the  utmost  importance 
in  tlie  diagnosis  of  gall-bladder  disease,  there  are  cases  in 
which  we  have  to  be  content  with  less  positive  evidence. 
A  special  value  of  Professor  RiedeFs  work  in  relation  to 
the  diagnosis  of  gallstones  lies  in  a  somewhat  startling  re- 
vision of  accepted  data  regarding  the  cardinal  symptoms 
of  this  disease.  Thus,  ten  of  the  fifty  cases  upon  which  he 
operated  had  never  had  colic  ;  only  fourteen  presented  a 
definite  tumor,  and  a  majority  had  never  had  jaundice. 

The  following  cases  are  of  interest  from  the  fact  that  a 
small  nodular  tumor  was  felt  in  both,  not  very  clearly  de- 
fined ;  in  one  the  history  of  severe  and  protracted  attacks 
of  colic  seemed  clearly  to  indicate  the  presence  of  gall- 
stones, while  in  the  other  case  the  condition  was  more 
doubtful. 

Case  XXXIX.  Severe  Attacks  of  Colic  for  Five  Years;  Nodu- 
lar Tumor  at  Edge  of  Liver;  Operation  with  Removal  of  Three 
Hundred  Gallstones. — August  W.,  aged  forty-two  years,  seen 
April  28,  1893.     Sent  by  Dr.  Salzer. 

Patient  is  a  large-framed,  well-built  man;  has  always  enjoyed 
excellent  health,  with  the  exception  of  malaria  twelve  or  thirteen 
years  ago.  Has  always  had  a  very  good  appetite  and  has  been  a 
heavy  eater.  He  has  not  been  a  dyspeptic,  but  has  been  troubled 
at  times  with  constipation,  but  until  the  onset  of  his  present  illness 
he  always  regarded  himself  as  a  very  healthy  man. 

He  comes  complaining  of  attacks  of  severe  and  protracted  pain 
in  the  abdomen,  which  began  five  years  ago.  While  walking  in 
the  garden  one  evening  he  had  severe  colicky  j)ains,  like  cramps, 
which  lasted  throughout  the  greater  part  of  the  night;  he  was  not 
jaundiced  and  the  attack  was  regarded  as  one  of  simple  colic.  Six 
months  afterward  he  had  a  second  and  more  severe  attack,  which 
came  on  suddenly  in  the  same  way.  Subsequently  the  attacks  be- 
came more  frequent,  and  he  had  at  least  six  or  seven  in  the  second 
year,  and  they  have  gradually  increased  until  he  has  been  rarely  a 
month  or  six  weeks  without  pain.  He  has  only  once  had  vomiting 
with  the  pains,  and  never  brought  up  any  blood;  has  never  had 


ll-i  THE  DIAGNOSIS  OP  ABDOMINAL  TUMORS. 

diarrhoea,  most  frequently  lias  been  constipated.  The  pain  begins 
as  a  rule  in  the  upper  abdomen,  radiates  to  the  back,  and  sometimes 
is  very  diffuse  throughout  the  back  and  sides.  Its  duration  varies 
extremely ;  thus,  the  day  before  yesterday  he  had  a  severe  attack ; 
yesterday  he  was  free  from  pain.  In  a  bad  attack  he  is  quite 
incapacitated,  and  can  not  straighten  himself  to  walk.  He  never 
has  had  bloody  urine  after  the  attacks.and  never  has  passed  gravel. 
The  early  part  of  this  winter  the  colic  was  very  severe  and  he  lost 
considerably  in  weight.  I  could  get  no  history  of  jaundice  from 
the  patient  or  from  his  wife,  but  Dr.  Salzer  informs  me  that  at  least 
twice  icterus  followed  the  attacks  of  severe  pain. 

Present  Condition. — Face  is  flushed;  color  good;  venules  of 
cheeks  a  little  dilated;  conjunctivae  not  stained. 

Abdomen  is  full;  panniculus  well  preserved;  on  palpation 
everywhere  soft.  In  nipple  line,  three  fingers'  breadth  below  cos- 
tal margin,  he  winces  on  pressure,  and  here  is  to  be  felt  an  irregu- 
larity at  the  edge  of  the  liver.  In  middle  line  the  edge  is  indefinite ; 
in  parasternal  line  the  liver  can  be  felt  about  two  fingers'  breadth 
below  margin,  and  there  is  an  ill-defined,  rounded,  somewhat  nodu- 
lar mass  in  this  situation,  which  moves  with  respiration.  It  is  sen- 
sitive on  deep  pressure.  Liver  dullness  begins  at  the  seventh  rib 
and  extends  to  the  costal  margin  in  parasternal,  and  a  finger's 
breadth  below  in  nipple  line. 

The  edge  of  the  spleen  is  not  palpable,  but  dullness  extends  from 
the  eighth  to  the  eleventh  ribs  in  midaxillary  line. 

The  stomach  is  not  dilated ;  thoracic  organs  negative. 

The  diagnosis  of  gallstones  was  made  and  he  was  advised  to 
have  an  operation. 

May  4th.— Dr.  Halsted  opened  the  abdomen  and  explored  the 
gall  bladder.  It  was  found  that  the  irregular  mass  at  the  edge  of 
the  liver  was  due  to  a  marked  projection  of  the  anterior  border. 
It  was  not  to  the  left  of  the  notch  of  the  gall  bladder  and  did  not 
form  a  definite  tongue-like  extension,  but  was  rather  an  irregular 
projection  of  the  border.  There  were  numerous  adhesions  between 
the  under  surface  of  the  liver  and  the  colon.  The  gall  bladder  did 
not  look  enlarged.  It  was  laid  open  and  found  to  contain  a  clear 
mucoid  fluid  and  about  three  hxindred  gallstones  of  various  sizes, 
chiefly  very  small,  but  one  at  the  orifice  of  the  cystic  duct  was  the 


TUMORS  OP   THE  GALL  BLADDER.  US 

size  of  a  small  cherry.    The  patient  reacted  well  from  the  operation, 
had  no  fever,  and  made  a  satisfactory  recovery. 

In  the  following  case,  led  astray  by  a  nodular  promi- 
nence at  the  edge  of  the  liver,  I  thought  the  condition  was 
possibly  gallstones  in  the  common  duct ;  but  unfortunately 
the  exploratory  laparotomy  did  not  give  us  any  definite  in- 
formation. 

Case  XL.  Enlarged  Liver;  Nodular  Tumor  at  Margin; 
thought  to  be  the  Fundus  of  Gall  Bladder. — Henry  L.,  aged 
thirty-three  years,  traveler  for  a  spirit  house,  was  admitted  Novem- 
ber 1,  1892,  complaining  of  jaundice. 

Father  died  at  sixty  years  of  paralysis;  mother  and  seven 
brothers  and  sisters  living  and  well. 

Patient  has  always  been  well  and  strong.  The  only  serious  dis- 
ease was  diphtheria  at  his  fifteenth  year.  Patient  has  been  a  pretty 
steady  drinker,  chiefly  of  beer ;  has  had  gonorrhoea,  and  was  under 
treatment  many  years  ago  for  syphilis,  the  constitutional  symp- 
toms of  which  were  very  slight.     He  has  never  had  haemorrhoids. 

He  has  not  been  feeling  very  well  for  a  year  or  more,  and  has 
been  depressed  in  spirits  owing  to  domestic  troubles.  He  has  been 
at  work  until  a  month  ago.  The  present  illness  began  two  months 
ago,  when  he  noticed  that  he  was  gradually  getting  yellow.  There 
were  no  pains  at  the  outset ;  no  colic ;  nor  had  he  nausea  or  vomit- 
ing. The  appetite  was  good ;  the  bowels  were  regular,  and  he  did 
not  feel  badly  enough  to  stop  work  for  more  than  a  month  after 
the  jaundice  appeared.  He  had  at  times  a  sense  of  weight  and 
dragging  in  the  liver  region,  but  never  any  pain.  He  has  lost 
gradually  about  twenty  pounds  in  weight  within  the  past  few 
months. 

Present  Condition. — Patient  is  a  well-built,  spare  man;  not 
specially  emaciated;  skin  and  conjunctivae  of  a  tolerably  intense 
yellow  color.  The  temperature  is  normal;  pulse  64,  full,  regular; 
tension  a  little  increased  and  the  vessel  wall  slightly  thickened. 
Thorax  is  barrel-shaped ;  resonance  everywhere  clear ;  no  adventi- 
tious sounds.  The  heart  beat  is  in  the  normal  position ;  the  sounds 
are  clear,  and  the  second,  at  the  aortic  cartilage,  is  decidedly  accen- 
tuated. 


116  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

Abdomen  is  enlarged,  particularly  in  tlie  upper  zone,  and  is 
prominent  in  the  right  hypochondriac  region.  On  palpation  the 
whole  of  the  right  hypochondriac  and  epigastric,  and  part  of  the 
umbilical  regions  ai'e  occupied  by  a  firm,  resistant  mass,  corre- 
sponding to  an  enlarged  liver.  The  lower  border  extends  to  within 
about  three  centimetres  of  the  umbilicus  and  passes  under  the  right 
costal  margin  at  the  junction  of  the  eighth  and  ninth  costal  carti- 
lages. The  flatness  begins  at  the  sixth  rib  in  the  nipple  line.  The 
surface  is,  as  a  rule,  smooth,  though  toward  the  navel  slight  irregu- 
larities are  felt.  The  edge  is  not  very  well  defined.  A  little  within 
the  nipple  line,  at  about  five  centimetres  to  the  right  of  the  navel, 
there  is  felt  on  deep  palpation  a  little  projection,  rounded,  some- 
what nodular,  and  which  appears  to  be  attached  to  the  liver  border. 
It  is  not  movable,  and  is  in  the  position  and  extremely  suggestive 
of  the  tip  of  the  gall  bladder  projecting  beneath  the  liver  margin. 
The  edge  of  the  spleen  was  just  palpable  on  deep  inspiration.  The 
splenic  flatness  began  in  the  eighth  interspace.  The  stomach  was 
not  dilated  and  the  gastric  juice  contained  free  hydrochloric  acid. 

The  urine  was  bile-stained,  clear,  acid,  1"025,  contained  a  trace 
of  albumin  and  a  few  hyaline  and  granular  casts. 

The  patient  remained  in  hospital  three  weeks.  The  jaundice 
varied  considerably  in  intensity,  and  the  complexion  got  at  times 
very  much  clearer.  The  stools  were  clay-colored,  and  at  no  time 
were  of  such  tint  as  to  indicate  that  at  any  rate  much  bile  passed 
into  the  intestine. 

During  his  stay  in  the  hospital  the  patient  gained  a  couple  of 
pounds  in  weight,  his  appetite  was  good,  and  he  was  always  able  to 
be  up  and  about. 

The  nature  of  the  trouble  did  not  seem  at  all  clear.  The  pa- 
tient's habits,  the  length  of  time  the  liver  had  been  enlarged,  the 
size  of  the  organ,  without  ascites,  favored  the  view  that  he  had  a 
form  of  hypertrophic  cirrhosis,  to  which  even  the  intensity  of  the 
jaundice  was  not  opposed.  The  question  of  syphilis  was  also  dis- 
cussed. The  stools,  however,  had  rather  the  character  of  a  defi- 
nitely obstructive  jaundice,  and  at  times  he  was  intensely  yellow. 
There  seemed  a  possibility  that  the  common  duct  was  obstructed, 
and,  though  he  had  not  the  intermittent  fever  and  chills  so  com- 
mon in  the  impaction  of  a  gallstone  in  this  part,  yet  the  jaundice 


TUMORS  OF  THE  GALL  BLADDER.  117 

was  variable,  and  the  nodular  mass  at  the  edge  of  the  liver  was 
suggestive,  to  say  the  least,  of  enlargement  of  the  gall  bladder.  He 
wished  for  an  operation  to  determine  the  nature  of  the  trouble,  and 
agreed  to  return  for  an  exploratory  laparotomy, 

January  S,  1893. — Patient  came  back  to- day  in  practically  the 
same  condition ;  but  he  has  gained  a  couple  of  pounds  in  weight. 
There  is  no  change  in  the  liver,  and  the  nodular  enlargement  can 
still  be  felt.  The  skin  is  deeply  jaundiced,  the  stools  clay-colored, 
and  the  urine  very  dark. 

6th. — This  morning  Dr.  Halsted  did  an  exploratory  laparotomy. 
An  incision  was  made  about  three  inches  below  the  costal  margin, 
just  above  the  border  of  the  liver  and  following  its  curve.  When 
the  peritonaeum  was  ojDened  there  appeared  to  view,  covering  the 
entire  surface  of  the  liver,  a  smooth  structure,  covered  by  perito- 
naeum, looking  like  omental  tissue,  containing  vessels  and  fatty 
tissue.  It  was  adherent  to,  but  could  be  moved  like  a  skin  upon 
the  surface  of  the  organ.  The  nature  of  it  was  doubtful.  There 
w^ere  numerous  adhesions  between  the  edge  of  the  liver  and  the 
transverse  colon,  which  had  to  be  separated,  and  the  lower  surface 
of  the  liver  was  united  by  adhesions  to  the  adjacent  parts.  In  the 
separation  of  the  adhesions  there  was  a  good  deal  of  bleeding,  and 
the  vessels  had  to  be  tied.  The  gall  bladder  was  not  found,  and  it 
was  impossible  under  the  circumstances  to  make  a  satisfactory  dis- 
section of  the  gastro-hepatic  omentum.  Nothing  abnormal  was 
felt  about  the  head  of  the  pancreas,  and  no  stone  could  be  felt  in 
the  duct.  The  edge  of  the  liver  itself  was  irregular,  and  at  a  little 
distance  from  the  margin  there  was  a  distinct  indentation  or 
groove.  The  nodular  mass  which  we  felt  so  repeatedly  was,  in  all 
probability,  a  projecting  portion  of  this  ledge-like  edge.  The  mem- 
branous fold  already  mentioned  was  loosely  adherent  to  the  sur- 
face of  the  liver,  and,  when  lifted  up,  there  were  numerous  bleed- 
ing points  which  had  to  be  touched  with  the  Paquelin  cautery. 
The  surface  was  somewhat  irregular,  roughened,  of  an  intensely 
bluish,  almost  plum  color,  and  looked  like  an  organ  in  a  state  of 
hypertrophic  cirrhosis. 

It  did  not  seem  possible  to  be  able  to  determine  precisely  the 
nature  of  the  remarkable  fold  of  membrane  covering  the  liver.  It 
covered  the  left  lobe  and  extended  up  as  far  as  could  be  felt.    It 


118  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

seemed  more  like  a  large  preperitoneal  membrane  covering  the 
liver.  It  was  outside  of  the  liver  capsule,  which  was  not  itself 
thickened. 

I  heard  from  this  patient  last  on  November  6,  1893.  His  jaun- 
dice had  all  disappeared,  and  the  stools  and  urine  are  natural.  He 
had  improved  a  good  deal,  but  the  dropsy  had  been  very  much 
worse,  and  he  had  been  tapped  twelve  times. 

(c)  Cancer  of  the  Gall  Bladder. — New  growths  of 
the  gall  bladder,  which  are  not  very  iincommon,  have  of 
late  attracted  much  attention,  particularly  in  their  rela- 
tion to  gallstones.  The  diagnosis  is  in  some  cases  easy,  in 
others  extremely  difficult,  and  if  the  patient  has  had  at- 
tacks of  gallstone  colic,  and  presents  a  rounded  tumor 
mass  below  the  edge  of  the  liver,  the  condition  is  very 
naturally  regarded  as  simple  dilatation  of  the  gall  bladder. 
The  following  cases,  which  have  been  under  observation, 
illustrate  certain  points  in  the  diagnosis : 

Case  XLI.  Persistent  Jaundice  with  Emaciation  and  As- 
cites; Nodular  Tumor  at  Edge  of  Right  io&e.— Magdalen  H., 
aged  fifty-two  years,  admitted  to  Ward  G  on  October  18,  1892, 
complaining  of  swelling  of  the  abdomen  and  legs. 

Her  father  died  of  tuberculosis.  No  history  of  cancerous  dis- 
ease of  the  family. 

The  patient  has  always  been  very  healthy,  was  married  at 
twenty-two  ;  had  one  child.  She  has  been  troubled  for  many 
years  with  constipation.     She  has  never  had  attacks  of  colic. 

The  present  illness,  dating  from  about  the  middle  of  June,  be- 
gan with  vomiting,  after  which  she  became  yellow  and  had  itch- 
ing of  the  skin.  The  jaundice  has  never  entirely  disappeared. 
The  legs  became  swollen  about  the  end  of  August,  and  the  abdo- 
men six  weeks  ago.  There  has  been  pain  in  the  back,  so  that  she 
always  has  to  lie  on  the  side;  otherwise  she  has  not  had  much  dis- 
tress. The  stools  have  been  yellow.  She  has  had  but  little  vom- 
iting. There  has  been  progressive  loss  of  weight,  and  she  has  be- 
come very  weak. 

Present  Condition. — Patient  is  much  emaciated,  and  has  an  in- 


TUMORS  OF  THE  GALL  BLADDER.  119 

tense  olive-green  jaundice.  Tliere  is  general  anasarca.  The  abdo- 
men is  extremely  distended,  and  the  lower  zone  of  the  thorax  is 
expanded.  Without  going  into  details  foreign  to  the  main  point, 
it  may  be  said  that  she  had  all  the  signs  of  obstructive  jaundice, 
and  an  ascites  which  required  frequent  tapping.  The  immediate 
interest  of  the  case  was  in  the  condition  of  the  liver.  After  tap- 
ping, the  liver  was  distinctly  palpable,  and  in  the  parasternal  line 
the  rounded  edge  could  be  felt  about  two  finger  breadths  from  the 
costal  margin.  Passing  toward  the  flank,  in  the  anterior  axillary 
line,  a  prominent  nodular  mass  was  reached,  and  here  the  liver 
margin  was  nearly  seven  centimetres  below  the  costal  margin. 
The  mass  felt,  about  the  size  of  a  walnut,  was  prominent,  not  um- 
bilicated.  No  other  masses  could  be  felt,  but  the  edge  of  the  liver 
in  the  parasternal  line  was  somewhat  irregular. 

RemarJcs.— This  illustrates  a  group  of  cases  of  obstructive 
jaundice  the  precise  cause  of  which  is  often  difBcult  to  determine. 
The  persistent  icterus  and  the  loss  of  weight  suggest  a  new  growth, 
but  whether  in  the  stomach,  the  pancreas,  or  the  liver  itself  is 
almost  impossible  to  say.  A  test  breakfast  shows  free  hydrochlo- 
ric acid,  and  she  has  not  had  much  vomiting  since  admission  to 
hospital.  The  stools  are  grayish  yellow,  not  fatty  and  not  sug- 
gestive of  pancreatic  disease.  The  nodular  body  at  the  right  bor- 
der is  the  main  objective  point  in  the  local  examination,  and  the 
question  discussed  between  Dr.  Thayer  and  myself  before  the 
class  has  been  whether  this  is  a  secondary  nodular  growth  or  the 
projecting  end  of  a  firm,  hard,  cancerous  gall  bladder.  To  my 
touch  it  rather  resembles  the  former,  feeling  as  though  the  finger 
could  be  passed  all  aroiind  the  Ivier  tissue  at  its  base.  Supposing 
it  to  be  secondary  cancer  of  the  liver,  the  organ  is  not  nearly  so 
large  as  is  common  in  this  condition  in  the  space  of  five  or  six 
months.  On  the  other  hand,  in  primary  cancer  of  the  gall  pas- 
sages the  liver  is  often  not  much  enlarged,  and  the  jaundice,  as  in 
this  case,  is  intense  from  the  outset.  A  point  in  favor  of  this  view 
is  the  absence  of  evident  signs  of  disease  of  the  stomach,  pancreas, 
or  intestines. 

Patient  died  November  16,  1892.  The  above  comments  were 
written  before  the  patient's  death.  The  autopsy  showed  a  primary 
carcinoma  of  the  gall  bladder,  the  end  of  which  was  the  nodular 


120  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

body  which  we  had  been  able  to  feel  so  definitely  on  palpation. 
The  walls  of  the  organ  were  greatly  thickened,  and  it  contained 
nearly  one  hundred  small  gallstones.  There  was  great  induration 
and  thickening  about  the  common  bile  duct,  the  head  of  the  pan- 
creas, and  in  the  gastro-hepatic  omentum.  The  common  duct 
passed  through  this  indurated  tissue  and  was  almost  occluded. 
The  liver  weighed  only  fifteen  hundred  grammes  and  presented 
numerous  medium-sized  cancerous  nodules  throughout  its  sub- 
stance. 

Case  XLII.  Cancer  of  the  Gall  Bladder;  Jaundice;  Pro- 
gressive Emaciation. — E.  S.,  aged  fifty-four  years,  admitted  to 
Ward  G  on  January  25,  1893,  complaining  of  pain  in  the  abdomen 
and  soreness  in  the  back.  There  is  nothing  of  any  moment  in  the 
family  history.  She  has  been  married;  has  had  six  children; 
four  miscarriages.  She  has  never  had  uterine  trouble  ;  no  serious 
illness  until  the  present  attack. 

More  than  a  year  ago  she  had  pains  in  the  back,  sometimes 
quite  severe,  and  accompanied  with  high-colored  urine.  After 
several  of  these  attacks  she  had  passed  small  calculi  in  the  urine. 
She  has  had  none  of  these  attacks  and  has  not  passed  a  stone  for 
about  a  year.  She  has  been  failing  in  health  for  the  past  few 
months,  has  had  indigestion,  belching,  and  occasional  attacks  of 
vomiting,  and  has  lost  a  good  deal  in  weight.  About  five  weeks 
ago  she  noticed  change  of  color  in  the  skin  and  that  she  was  get- 
ting yellow,  and  for  about  the  same  time  she  has  had  a  dull  ach- 
ing pain  on  the  right  side  of  the  abdomen.  The  urine  has  been 
high-colored,  and  the  stools,  which  formerly  were  very  dark, 
were  light-gray  in  color. 

The  patient  is  a  medium-sized  woman ;  face  thin,  but  the  body 
and  limbs  still  well  nourished.     There  is  moderate  jaundice. 

Abdomen  full;  panniculus  well  retained.  On  palpation,  it  is 
soft,  nowhere  painful  except  at  a  point  about  five  centimetres  be- 
low the  costal  margin  in  the  nipple  line.  Here  there  is  a  firm 
mass  which  extends  to  the  left  to  within  six  centimetres  of  the  um- 
bilicus, and  at  this  border  the  fingers  can  be  placed  directly  be- 
neath it.  Below  it  reaches  to  the  transverse  navel  line,  and  is  here 
rounded,  and  the  fingers  can  not  be  placed  so  well  beneath  it  as  to 
the  left.    To  the  right  the  margins  are  not  very  clearly  defined,  but 


TUMORS  OP  THE   GALL  BLADDER.  121 

it  extends  nearly  to  the  tip  of  the  tenth  rib.  Above,  it  can  not 
be  separated  from  the  liver  margin.  It  feels  like  a  rounded  mass 
larger  than  a  lemon,  is  extremely  resistant,  hard,  and,  though  it 
has  the  situation  of  the  gall  bladder,  it  scarcely  conveys  the  im- 
pression of  the  rounded,  pear-shaped  outline  of  that  organ.  The 
right  kidney  can  not  be  felt.  The  liver  dullness  is  not  present  in 
the  midsternal  line,  just  three  centimetres  and  a  half  in  the  para- 
sternal and  five  centimetres  in  the  nipple  line.  The  mass  above 
described,  though  directly  continuous  with  the  liver,  presents  a  flat 
tympany  on  percussion.  Deep  pressure  from  behind  in  the  right 
flank  presses  the  tumor  mass  forward. 

The  spleen  is  not  enlarged,  stomach  not  dilated,  and  the  pelvis 
is  clear.  The  urine  is  very  dark  in  color,  1-016,  pale;  bile  pigments 
present ;  no  sugar ;  a  few  granular  casts.  The  stools  are  clay-col- 
ored and  very  oflPensive.  Repeated  examinations  showed  no  essen- 
tial change  in  the  condition  of  the  tumor  mass.  The  jaundice  be- 
came very  much  more  intense,  though  the  general  symptoms  were 
somewhat  ameliorated.  She  took  her  food  better,  and  had  much 
less  pain. 

The  case  was  regarded  as  tumor  of  the  gall  bladder  associated 
with  gallstones,  and  probably  malignant  disease.  The  patient's 
condition  was  so  satisfactory  that  it  was  thought  advisable  to 
have  an  exploratory  operation  to  determine  if  anything  could 
be  done. 

February  8th. — This  morning  Dr.  Halsted  made  an  exploratory 
operation.  The  mass  above  described  was  in  the  situation  already 
referred  to— between  the  transverse  colon  and  the  under  surface  of 
the  liver,  to  which  it  was  firmly  attached.  The  adhesions  to  the 
colon  were  so  tight  that  it  was  not  thought  advisable  to  attempt  to 
separate  them.  The  tumor  mass  was  firm,  solid,  and  grayish  white 
in  color,  passed  beneath  the  surface  of  the  liver,  and  occupied  the 
position  of  the  gall  bladder.  The  liver  itself  was  not  enlarged,  but 
the  edge  could  readily  be  felt  about  six  centimetres  above  the  lower 
border  of  the  tumor  mass. 

The  jaundice  persisted:  she  got  progressively  emaciated;  the 
wound  healed.  Her  friends  took  her  home  on  March  2d,  where 
she  subsequently  died. 

Carcinoma  of  the  gall  bladder  is  not  very  easy  to  rec- 


122  TEE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

ognize,  but  there  are  certain  suggestive  features  in  sus- 
pected cases.  The  disease  is  most  common  in  women — two 
thirds  of  the  cases  collected  by  Musser.  In  seven  eighths 
of  the  cases  the  cancer  has  been  associated  with  gallstones, 
so  that  a  history  of  colic  or  of  previous  jaundice  should  be 
sought  for.  Rapid  emaciation,  with  or  without  jaundice, 
and  the  development  of  a  cachexia  within  three  or  four 
months,  speak  for  cancer;  simple  hydrops  vesicae  may 
persist  for  months  without  impairment  of  the  general 
health.  Chills  and  fever  are,  as  a  rule,  against  neoplasm. 
So  long  as  the  disease  is  confined  to  the  gall  bladder  jaun- 
dice is  not  present,  but  when  it  extends  to  the  common 
duct  the  icterus  is  intense  and  persistent.  Ascites  may  be 
caused  by  the  propagation  of  the  disease  to  the  perito- 
naeum by  pressure  of  secondary  masses  on  the  vena  portae, 
by  extension  to  the  gastro-hepatic  omentum,  as  in  Case 
XLI,  and  occasionally  is  due  to  thrombosis  of  the  portal 
veins. 

The  local  features  are  variable  and  uncertain.  In  the 
cases  I  have  narrated  the  walls  of  the  gall  bladder  were 
infiltrated,  but  the  cancer  may  be  at  the  outlet,  causing 
obstruction  with  great  dilatation  and  a  tumor  resembling 
in  all  respects  that  produced  by  any  other  occlusion  of  the 
cystic  duct.  When  the  fundus  is  involved  the  tumor  is 
harder,  more  resistant,  not  so  movable  as  in  simple  hy- 
drops, and  the  growth  may  be  very  rapid.  The  liver  is 
not  usually  much  enlarged,  even  when  secondary  nodules 
are  present.  Aspiration  of  the  tumor  gives  most  impor- 
tant indications.  A  clear  mucoid  fluid  favors  gallstones ; 
turbid,  albuminous  contents  suggest  neoplasm,  as  does 
also  blood  or  a  blood-stained  fluid.  Fragments  of  the 
new  growth  may  be  found  in  the  material  aspirated. 
Pure  bile  is  rather  in  favor  of  gallstones,  and  indicates 
that  the  cystic  duct  is  not  involved. 

But  taking  all  the  circumstances,  general  and  local. 


TUMORS  OF  THE  GALL  BLADDER,  123 

into  consideration,  you  may  not  be  able  to  reach  a  conclu- 
sion, in  which  case  remember  that  the  hazard  of  an  ex- 
ploratory operation  is  slight,  and  that  by  far  the  most 
frequent  cause  of  tumor  in  the  region  of  the  gall  bladder 
is  cholelithiasis. 


13 


LECTURE  V. 

TUMORS  OF  THE  INTESTINE,  OMENTUM,  AND  PANCREAS  ; 
MISCELLANEOUS  TUMORS. 

1.  Tumors  of  the  Intestine. — Cancer,  the  common  cause 
of  tumor,  occurs  most  frequently  (apart  from  the  rectum) 
in  the  caecum  and  the  sigmoid,  hepatic,  and  splenic  flex- 
ures of  the  colon.  Not  one  of  the  three  cases  which  have 
been  under  observation  presented  a  typical  group  of 
symptoms,  but  singly  and  together  they  illustrate  many 
interesting  features  of  the  disease.  In  the  first  place,  the 
affection  may  be  latent,  revealed  at  autopsy  alone,  or  the 
early  and  indeed  the  chief  symptoms  may  be  due  to  the 
secondary  tumors.  The  first  case  illustrates  very  well 
the  latency  of  the  disease.  Without  intestinal  symptoms, 
for  some  months  after  he  came  under  observation  the  sole 
objective  feature  was  the  progressive  enlargement  of  the 
liver.  Only  six  weeks  before  his  death,  after  he  had  be- 
come greatly  emaciated,  we  discovered  a  tumor  in  the 
right  iliac  region,  and  subsequently  he  had  haemorrhage 
from  the  bowel. 

Case  XLIII.  Cancer  of  the  Ccecum  and  Colon;  Latent 
Course ;  Enormous  Secondary  Enlargement  of  Liver.— John  E., 
aged  twenty-nine  years,  admitted  February  6,  1892  ;  under  ob- 
servation until  September  25th.  The  family  history  is  good.  The 
patient  was  healthy  and  strong  until  four  years  ago,  when  he  had 
severe  malaria.  For  eight  months  prior  to  his  admission  he  had 
not  been  very  well,  and  had  had  irregular  pains  in  the  abdomen. 
During  the  past  eight  months  he  has  been  pale,  has  felt  weak, 

124 


TUMORS  OF  THE  INTESTINE.  125 

has  not  been  able  to  work,  and  on  several  occasions  he  has  been 
slightly  jaundiced.  His  appetite  has  been  good;  bowels  regular; 
has  had  no  diarrhoea.  For  several  months  past  he  has  noticed 
that  the  upper  part  of  the  abdomen  was  swollen  and  tender  to  the 
touch.  On  admission,  the  patient  was  pale,  but  looked  well  nour- 
ished; no  fever;  pulse  86.  The  lower  thoracic  zone  is  much  ex- 
panded, particularly  on  the  right  side.  The  epigastric  and  hy- 
pochondriac regions  bvdge  in  a  very  prominent  manner,  and  there 
is  a  rounded  mass,  nine  centimetres  in  transverse  extent,  which  ex- 
tends from  under  the  ribs  on  the  right  side.  In  the  median  line 
the  edge  is  clearly  defined,  and  reaches  to  within  four  centimetres 
of  the  navel.  To  the  left  it  extends  far  over  beyond  the  para- 
sternal line,  and  to  the  right  deep  into  the  lumbar  region.  The 
percussion  over  this  large  mass  is  flat  and  continuous  with  the 
liver  dullness,  which  begins  in  the  median  line  at  the  base  of  the 
xiphoid,  in  the  nipple  line  at  the  sixth  cartilage,  and  in  the  axilla 
at  the  seventh.  Although  there  was  no  fever  and  no  definite  his- 
tory of  any  intestinal  trouble,  the  patient's  age  and  good  condition 
seemed  against  the  diagnosis  of  cancer  of  the  liver.  Accordingly 
an  aspirator  needle  was  thrust  in  at  the  prominent  part,  but  only 
blood  obtained.  Under  observation  the  liver  evidently  increased 
in  size,  and  there  seemed  to  be  no  question  that  it  was  a  new 
growth.  The  question  then  arose  as  to  the  primary  seat  of  the  dis- 
ease. The  stomach  symptoms  were  insignificant,  he  had  no  vomit- 
ing, the  appetite  was  good,  and  a  test  breakfast  was  readily  dis- 
posed of.  Subsequently,  in  August,  very  careful  examination  of 
the  abdomen  revealed  a  hard  mass  low  down  in  the  flank.  It  was 
usually  ill-defined,  but  on  several  occasions  Dr.  Thayer  thought 
that  it  was  qviite  distinct.  There  was  no  diarrhoea;  no  special 
change  in  the  faeces,  which  were  always  well  formed.  He  re- 
mained under  observation  outside  the  hospital  during  the  summer. 
The  liver  tumor  did  not  increase  very  much  in  size.  He  became 
progressively  weaker  and  very  much  emaciated.  Two  weeks  be- 
fore death  he  passed  two  large  stools  containing  clots  of  blood. 
He  became  extremely  emaciated  before  his  death. 

Autopsy. — The  liver  weighed  seven  thousand  two  hundred 
grammes;  the  right  lobe  was  much  disfigured,  and  presented 
numerous  nodular  tumors  with  elevated  margins  and  depressed 


126  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

centers.  A  distinct  groove  marked  ofip  the  anterior  margin  of  the 
right  lobe  from  the  rest  of  the  organ.  On  section,  secondary  can- 
cerous nodules  were  found  scattered  through  the  entire  organ. 
The  primary  growth  was  found  to  be  at  the  head  of  the  caecum 
and  the  beginning  of  the  colon,  which  presented  an  extensive  fun- 
gating  mass,  softened  and  necrotic  on  the  surface.  The  meso- 
colon was  thickened  and  the  glands  much  involved.  Micro- 
scopically the  tumor  proved  to  be  a  cylindrical-celled  epithelioma. 
Extensive  secondary  nodules  were  scattered  through  the  lungs. 

In  the  following,  by  far  tlie  most  interesting  and  in- 
structive case  of  the  series,  intestinal  symptoms  were  ab- 
sent throughout,  and  the  presence  of  a  solid,  firm  mass 
deep  in  the  right  side  led  us  to  think  at  first  that  there  was 
a  renal  tumor.  I  give  you  the  notes  just  as  I  dictated 
them  from  day  to  day,  as  they  illustrate  the  erroneous  di- 
agnosis, and  the  gradual  development  of  features  which 
led  to  its  revision. 

Case  XLIV.  Tumor  in  Right  Flank ;  Suspected  to  he  a  Renal 
Sarcoma  ;  Subsequent  Development  of  Dilatation  of  the  Stomach 
and  Signs  of  Tumor  in  the  Bowel. — Thomas  B.,  aged  thirty-two 
years,  admitted  August  3,  1892,  complaining  of  pains  in  the  abdo- 
men. There  was  nothing  of  special  moment  in  his  family  history. 
Present  illness  began  about  eighteen  months  ago  with  griping  pains 
in  the  abdomen,  attacks  of  which  occurred  from  time  to  time  and 
were  attributed  to  indiscretions  in  diet.  On  the  voyage  to  this 
country,  ten  months  ago,  he  was  very  seasick,  and  had  a  great  deal 
of  pain  in  the  abdomen ;  and  then  for  the  first  time  he  noticed  a 
hardness  or  lump  on  the  right  side.  The  bowels  were,  as  a  rule, 
constipated.  He  has  never  passed  blood  in  the  stools  or  in  the 
urine.  For  some  months  he  has  been  gradually  losing  in  weight, 
and  has  been  getting  pale  and  weak.  When  in  good  condition  he 
weighs  one  hundred  and  seventy -seven  pounds ;  he  now  weighs  one 
hundred  and  twelve  pounds. 

Present  Condition.— Patient  is  a  tall,  well-built  man,  pale, 
scarcely  cachectic.  The  tongue  is  moist,  slightly  coated ;  pulse  104, 
of  fair  volume.     The  examination  of  the  thoracic  organs  is  nega- 


TUMORS  OF  THE  INTESTINE. 


127 


tive.  The  abdomen  is  symmetrical,  but  looks  a  little  fuller  in  the 
right  flank.  The  right  hypochondriac  and  lumbar  regions  are 
filled  with  a  firm,  somewhat  irregularly  rounded  mass,  which  on 
bimanual  palpation  can  be  readily  moved  up  and  down.  On  mak- 
ing firm  pressure  with  the  left  hand  in  the  right  renal  region  the 
mass  becomes  apparent  beneath  the  skin  just  to  the  right  of  the 
navel.  To  the  left  it  extends  almost  to  the  middle  line ;  the  lower 
border  is  three  centimetres  below  the  transverse  navel  line.  Both 
the  lower  and  the  left  borders  are  roimded,  but  toward  the  right, 
just  beneath  the  tip  of  the  eleventh  rib,  there  is  a  distinct  nodule  to 
be  felt.  In  its  anterior  part  it  can  be  separated  distinctly  from  the 
liver  both  by  palpation  and  percussion,  but  in  the  anterior  axillary 
line  the  tumor  passes  beneath  the  ribs,  and  the  dullness  is  here  con- 
tinuous with  that  of  the  liver.  On  percussion  there  is  resonance 
over  the  tumor  mass  to  the  left  of  the  nipple  line.  The  general 
situation  of  the  tumor  is  indicated  in  the  annexed  chart.  There 
are  no  glandular  enlargements.  The 
spleen  is  not  palpable  and  the  dull- 
ness is  almost  obliterated. 

The  patient  has  no  sweats,  no 
cough.  There  is  a  leucocytosis,  the 
white  corpuscles  numbering  over 
twenty  thousand  to  the  cubic  milli- 
metre ;  haemoglobin,  forty-one  per 
cent. ;  red  blood-corpuscles  slightly 
over  four  million  to  the  cubic  milli- 
metre. The  urine  (many  examina- 
tions) has  usually  been  clear,  acid  ; 
specific  gravity,  1'012  ;  at  first  no  al- 
bumin, but  subsequently  slight  traces. 
No  sugar  ;  microscopically,  a  few 
blood-cells,  but  as  a  rule,  even  after 
centrifugalizing,  neither  casts  nor 
blood-cells  were  found.  The  sedi- 
ment obtained  was  also  examined  for  tubercle  bacilli,  with  negative 
result.  The  temperature  was  at  times  a  little  above  normal,  and  on 
the  evening  of  the  20th  of  August  he  had  a  chill,  the  temperature 
rising  to  103'5°.     On  the  6th  of  September  a  medium-sized  aspirator 


Fig.  33.— Outline  of  the  tumor  mass 
in  Case  XLIV. 


128  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

needle  was  thrust  upward  and  backward  beneath  the  twelfth  rib, 
and  a  little  blood-stained  fluid  removed,  which  contained  round 
cells  twice  the  size  of  leucocytes.  The  needle  seemed  imbedded 
in  the  firm  substance.  The  patient  objected  to  an  exploratory  op- 
eration. 

The  situation  and  shape  of  the  tumor,  the  mobility,  and 
the  readiness  with  which  it  could  be  pushed  forward  by 
pressure  from  behind  pointed  to  a  renal  origin.  The  na- 
ture of  the  growth  was  less  certain.  If  he  is  correct  in  dat- 
ing the  first  symptoms  as  far  back  as  eighteen  months  the 
tumor  has  not  attained  the  size  usually  reached  by  new 
growths  of  the  kidney  within  this  time.  There  has  also 
been  no  blood  in  the  urine.  The  single  chill  does  not  speak 
specially  against  new  growth.  Can  it  be  tuberculous  ne- 
phritis ?  The  family  history  is  good  ;  the  urine  is  and  has 
been  clear ;  there  is  no  involvement  of  the  epididymus,  and 
fever  has  not  been  a  marked  feature.  If  the  tumor  were 
due  to  saccular  dilatation  following  occlusion  by  tuber- 
culous or  calculous  disease,  certainly  the  aspirator  would 
have  withdrawn  purulent  fluid,  and  there  would  have  been 
at  some  time  pus  in  the  urine.  The  rapid  loss  in  weight 
points  strongly  in  favor  of  new  growth. 

October  12th. — The  patient  was  shown  in  clinic  this  morning. 
The  emaciation  has  progressed ;  he  has  had  for  ten  days  much  more 
fever,  and  a  chill  on  the  sixth  in  which  the  temperature  rose  to 
nearly  104° ;  on  the  seventh,  eighth,  and  ninth  it  remained  between 
102°  and  103°.  There  are  no  special  changes  in  the  urine.  He 
has  been  at  times  constipated,  but  the  stools  show  nothing  peculiar. 
The  tumor  mass  has  not  increased  matei'ially  in  size,  though  per- 
haps it  reaches  a  little  further  toward  the  navel. 

The  patient  says  that  be  notices  flatus  bubbling  in  the  vicinity 
of  the  tumor,  and  that  it  divides  into,  as  he  expresses  it,  two  or 
three  portions.  The  hand  placed  on  the  tumor  experiences  occa- 
sionally a  feeling  as  if  gas  was  escaping  through  it,  and  the  left 
half  is  resonant;  but  this  might  be  due  to  the  presence  of  the  colon 
over  the  mass. 


TUMORS  OF  THE  INTESTINE.  129 

This  morning,  with  the  students,  the  various  probabilities  of  renal 
sarcoma,  or  tuberculosis,  or  calculous  pyelitis  were  discussed.  The 
state  of  the  urine  and  the  failure  of  aspiration  to  draw  fluid  seem 
opposed  to  the  latter  conditions.  The  chills  and  fever  were  not 
thought  to  be  inconsistent  with  sarcoma. 

The  question  was  also  discussed  as  to  whether  it  really  was  a 
renal  timior,  and  whether  it  might  not  be  associated  with  the  liver 
or  with  the  hepatic  flexure  of  the  colon.  It  did  not  seem  possible, 
with  the  evidence  at  our  disposal,  to  reach  a  definite  diagnosis. 

Since  the  above  note  of  October  12th  there  have  been  several  de- 
velopments in  this  case. 

15th.— For  the  past  two  days  the  patient  has  had  a  great  deal  of 
vomiting,  often  bringing  up  large  quantities.  Last  night  he  vom- 
ited eight  hundred  cubic  centimetres  of  brownish  fluid  containing 
half-digested  food.  The  reaction  was  acid,  the  odor  rancid,  and 
tests  for  free  hydrochloric  acid  were  negative. 

16th.— Ewald's  test  breakfast  given  this  morning,  and  withdrawn 
fifty  minutes  later,  gave  nearly  three  hundred  cubic  centimetres  of 
a  slightly  grayish,  muddy  fluid,  containing  comparatively  little  food 
matter.  It  was  acid  in  reaction,  odor  rancid  and  sour,  turned  congo 
paper  blue,  and  gave  a  very  distinct  rosy-red  color  with  the  phloro- 
glucin- vanillin  solution.  Microscopically,  there  were  fat  crystals, 
undigested  food  stuffs,  numerous  bacilli,  and  yeast  cells. 

17th. — The  vomiting  has  continued  during  the  past  twenty-four 
hours,  and  he  does  not  look  so  well  to-day.  The  tumor  mass  occu- 
pies the  right  hypochondriac  region,  extends  into  the  right  lumbar 
and  umbilical  regions,  but  not  into  the  epigastric,  reaching  appar- 
ently to  within  about  two  centimetres  of  the  navel.  Below,  it  ex- 
tends exactly  eight  centimetres  from  the  costal  margin  in  the  nip- 
ple line.  The  greatest  prominence  is  just  below  the  point  of  the 
tenth  rib.  On  first  palpating  it  this  morning  there  was  at  the  lower 
margin  a  prominent  rounded,  ridge-like  mass,  firm  and  hard,  which 
gradually  disappeared,  feeling  as  if  it  were  a  tubular,  muscular 
structure  in  contraction.  Again  this  morning  gas  was  felt  bub- 
bling through  the  mass.  Percussion  over  it  gave  flat  tympany ; 
slight  change  noted  in  rolling  the  patient  over  on  the  left  side.  At 
a  second  visit  to-day  there  were  noticed  for  the  first  time  waves  of 
peristalsis  crossing  the  upper  abdomen  from  left  to  right,  and  the 


130 


THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 


outlines  of  the  stomach  could  he  distinctly  seen,  the  lower  border 
reaching  to  the  navel.  At  the  time  of  the  passing  of  the  waves  the 
"walls  of  the  stomach  became  firm,  and  bubbles  of  gas  could  be  felt 
passing  through  the  tumor. 

20th. — The  signs  of  dilatation  of  the  stomach  have  been  for  the 
past  few  days  unusually  distinct.     He  has  had  vomiting  of  large 


quantities  of  liquid.     The   amount  of  urinary   secretion  is  very 
scanty.     He  sank  gradually  and  died  on  the  20th. 

Autopsy. — By  Dr.  Flexner.    On  opening  the  abdomen  the  stom- 
ach was  seen  to  be  greatly  dilated,  reaching  considerably  below  the 


TUMORS  OF   THE  INTESTINE.  131 

level  of  the  navel  (Fig.  35).  In  the  right  hypochondriac  region  a 
tumor  mass  was  adherent  in  part  to  the  anterior  abdominal  wall, 
just  between  the  costal  margin  and  the  crest  of  the  ilium.  Just  be- 
low the  hepatic  flexure  of  the  colon  there  was  a  tumor  the  size  of  an 
orange  completely  encircling  the  bowel.  It  was  seven  centimetres 
in  length  and  eight  centimetres  in  circumference.  The  coats  were 
uniformly  infiltrated  and  the  tissue  looked  infiltrated  witli  colloid. 
The  inner  surface  was  ulcerated  and  the  lumen  of  the  bowel  not 
here  narrow.  The  caecum  and  ascending  colon  were  opened  in  situ. 
At  the  hepatic  flexure  the  tumor  mass  was  adherent  to  the  right  lobe 
of  the  liver  and  behind  was  attached  to  the  kidney.  The  finger, 
introduced  into  the  colon  at  this  region,  entered  a  number  of  pock- 
ets, one  of  which  directly  led  into  the  liver  substance.  On  its  pos- 
terior surface  and  to  the  right  the  tumor  was  closely  united  to  the 
curve  of  the  duodenum,  into  which  it  had  grown  in  such  a  way  as 
to  cause  a  distinct  narrowing.  The  mucous  membrane  of  the 
duodenum  was  ulcerated  from  the  central  part  of  the  tumor,  but 
was  intact  elsewhere.  The  stomach  was  greatly  dilated;  the  mu- 
cous membrane  smooth.  The  pylorus  itself  and  first  part  of  the 
duodenum  were  greatly  stretched ;  the  groove  between  them  is  well 
seen  in  the  figure.  The  finger  could  be  passed  into  the  duodenum, 
but  the  narrowed  lumen  would  not  more  than  admit  the  tip  of  the 
little  finger.  The  liver  showed  numerous  secondary  nodules  of 
cancer.  The  mesenteric  glands  were  enlarged  and  contained  meta- 
static nodules. 

The  third  case  presented  a  very  prominent  movable 
tumor  which,  from  its  general  characters  and  situation, 
seemed  to  be  connected  with  the  bowel,  though  the  intes- 
tinal symptoms  were  here  also  quite  in  the  background. 

Case  XLV.  Tumor  in  Right  Flank;  Removal  of  Groivth  in 
Ccecum  and  Ascending  CoZow.— Sylvester  H.,  aged  sixty  years, 
admitted  October  15th,  complaining  of  a  lump  in  the  abdomen. 
He  has  been  a  very  healthy  man.  For  two  years  past  has  had 
slight  pain  after  eating,  with  nausea  and  constipation. 

His  present  illness  began  about  three  months  ago  with  trouble- 
some constipation,  and  three  or  four  days  would  pass  without  a 
movement  from  the  bowels,  and  the  faeces  would  be  hard  and 
14 


132 


THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 


lumpy.  He  took  medicine  for  it,  since  which  time  the  howels  have 
heen  rather  loose,  the  stools  yellow  and  containing  slime,  but 
never  blood.  No  tenesmus,  no  cramps.  Five  weeks  ago  he  had 
an  attack  of  vomiting,  followed  by  a  second  attack  a  week  later  ; 
brought  up  sour  material  ;  no  blood.  In  the  past  three  months  he 
has  lost  a  great  deal  in  weight,  and  has  become,  he  thinks,  a  little 
pale.  He  has  been  short  of  breath  on  exertion,  and  lately  the  feet 
have  been  swollen. 

Present   Condition.— 'Pa.iient  looks  a  little  pale,  but  is  fairly 
well  nourished  ;   no  fever  ;  tongue  slightly  furred.     Abdomen  is 

full,  and  about  six  centimetres  to  the 
right  of  the  navel  there  is  a  projec- 
tion beneath  the  skin,  uninfli;enced 
in  position  by  the  respiratory  move- 
ments. On  palpation  this  is  felt  to 
correspond  to  a  rounded  nodular  mass, 
feeling  of  about  the  size  of  a  cricket 
ball,  situated  midway  between  the 
navel  and  the  anterior  superior  spine 
of  the  ilium.  It  feels  very  superficial ; 
is  not  tender  ;  is  very  hard  ;  and  one 
or  two  ridges  can  be  felt  upon  it. 
There  are  no  changes  in  its  consist- 
ence. On  deep  inspiration  it  descends 
slightly.  It  is  freely  movable  and  can 
be  pushed  over  as  far  as  the  navel. 
No  gas  is  to  be  felt  to  bubble  through 
it.     On  light  percussion  there  is  a  flat  tympany  over  it. 

As  the  patient  had  had  very  few  intestinal  sj'raptoms  and  had 
had  dyspepsia  for  several  years,  with  recently  two  attacks  of  vomit- 
ing, the  attention  was  naturally  directed,  in  the  first  place,  to  the 
condition  of  the  stomach.  Palpation  was  negativ'e  in  the  region  of 
the  pylorus.  There  was  no  clapotage.  The  organ  did  not  appear 
to  be  dilated.  The  upper  limit  of  resonance  was  at  the  fifth  rib  in 
the  nipple  line,  and  the  lower  limit  above  the  navel.  On  October 
17th  the  tests  for  free  hydrochloric  acid  were  negative.  On  the 
21st  it  seemed  that  the  stomach  tympany  was  somewhat  more  ex. 
tensive  than  before.     There  were  no  peristaltic  waves.     On  several 


FiQ.  35.— Situation  of  the  tumor  in 
Case  XLV. 


TUMORS  OF  THE  INTESTINE.  133 

occasions  a  test  breakfast  was  given,  and  on  October  26th  the 
mucus  withdrawn  was  blood-stained  ;  no  free  hydrochloric  acid. 
The  tumor  could  be  readily  separated  from  the  liver  and  could  be 
moved  far  down  into  the  right  iliac  fossa.  While  the  symptoms  in 
this  case  pointed  rather  to  disease  of  the  stomach,  the  situation  and 
general  character  of  the  tumor  were  those  of  an  intestinal  growth- 
The  stomach,  too,  seemed  somewhat  relaxed,  and  the  absence  of 
free  hydrochloric  acid  was  suggestive. 

On  November  7th  Dr.  Halsted  operated  and  found  that  the 
tumor  occupied  the  caecum  and  the  commencement  of  the  ascend- 
ing colon.  It  was  readily  removed.  The  patient  seemed  to  do 
very  well,  taking  his  nourishment  and  gaining  in  strength  until 
the  13th,  when,  after  an  attack  of  nausea  and  coughing,  the  stitches 
gave  way  and  about  two  feet  and  and  a  half  of  the  small  intestine 
protruded.  He  became  very  restless,  gradually  sank,  and  died  the 
same  day.  The  tumor  was  a  cylindrical-celled  epithelioma,  involv- 
ing the  entire  circumference  of  the  gut,  but  excavated  and  not 
narrowing  in  any  way  the  lumen  of  the  gut.  The  autopsy  showed 
an  interesting  feature — namely,  the  presence  also  of  a  cancer  on 
the  posterior  wall  of  the  stomach  and  of  a  second  small  tumor 
mass  in  the  jejunum. 

In  the  diagnosis  of  cancer  of  the  intestine  the  follow- 
ing points  may  be  taken  into  consideration.  In  compari- 
son with  the  subjects  of  malignant  disease  of  the  stomach 
very  many  of  the  patients  are  young;  thus  you  have 
noticed  that  Case  XLIII  was  only  twenty-nine  years  of 
age,  and  Case  XLIV  was  only  thirty-two.  Intestinal 
features  are  present  in  a  majority  of  cases,  though  they 
were  by  no  means  suggestive  in  the  patients  who  have  been 
under  our  observation.  Griping,  colicky  pains  are  com- 
mon, even  without  the  signs  of  obstruction.  With  nar- 
rowing of  the  lumen  of  the  gut  very  characteristic  features 
occur — attacks  of  severe  griping  pain,  abdominal  disten- 
tion, the  presence  of  active,  sometimes  visible  peristalsis 
in  the  distended  coils  of  bowel,  and,  if  the  condition  per- 
sists, vomiting  and  all  the  signs  of  intestinal  obstruction. 


134  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

In.  the  case  of  Sylvester  H.,  I  called  your  attention  repeat- 
edly to  the  fact  that  the  intestinal  symptoms  depended 
largely  upon  the  state  of  the  lumen  of  the  bowel  at  the 
seat  of  the  tumor.  If  fungous  masses  project  and  cause 
more  or  less  narrowing,  colicky  pains  and  constipation  are 
inevitable ;  but,  on  the  other  hand,  as  the  tumor  grows,  if 
there  is  necrosis  of  its  surface,  with  excavation,  neither 
pain  nor  constipation  may  be  present.  Diarrhoea  and  the 
passage  of  much  slime  with  the  faeces  are  not  infrequent 
symptoms.  Haemorrhage  is  also  common.  The  blood  is 
not  often  in  large  quantities;  when  the  tumor  is  in  the 
sigmoid  flexure  it  may  be  bright  and  very  little  changed, 
but  in  growths  about  the  caecum  it  is  often  much  altered 
before  it  appears  in  the  stools.  There  are  cases  in  which 
constant  loss  of  small  quantities  of  blood  is  a  very  special 
feature,  and  the  patient  becomes  profoundly  anaemic. 
Sloughy  fragments  of  the  tumor  may  sometimes  be  passed 
in  the  faeces. 

A  cachexia  develops  progressively  but  with  very  vari- 
able rapidity.  It  may,  however,  be  well  marked  before  any 
features  have  arisen  suggestive  of  intestinal  trouble.  The 
loss  in  weight  may,  too,  be  slight,  even  after  the  tumor  has 
persisted  for  many  months.  There  is  at  present  a  patient 
in  Ward  C  with  a  tumor  in  the  right  iliac  region,  which 
has  persisted  for  nine  or  ten  months,  and  upon  the  nature 
of  which  very  many  opinions  have  been  expressed.  She  is 
well  nourished,  but  profoundly  anaemic.  It  did  not  seem 
possible  from  the  symptoms,  general  or  local,  to  make  a 
definite  diagnosis,  but  an  exploratory  operation  showed  an 
extensive  new  growth  in  the  caecum.  Another  patient, 
who  had  repeated  small  haemorrhages,  developed  an  ex- 
treme anaemia  with  retention  of  the  general  fatty  pannicu- 
lus.  When  extensive  secondary  growths  develop,  as  in 
Case  XLIII,  the  cachexia  may  be  profound.  The  tumor  in 
cancer  of  the  intestines  may  be  readily  and  easily  dis- 


1 


OMENTAL  TUMORS.  135 

covered — indeed,  evident  on  inspection,  as  in  Case  XLV. 
On  the  other  hand,  as  in  Case  XLIII,  it  may  not  be  until 
the  terminal  stage  of  the  disease  that  the  growth  is  found. 
A  small  tumor  of  the  hepatic  or  splenic  flexure  of  the  colon 
may  escape  repeated  examinations.  Mobility  is  a  special 
feature  of  growths  in  the  large  bowel.  Large  tumors, 
however,  of  the  csecum  may  be  quite  fixed.  The  most 
movable  growths  are  those  connected  with  the  sigmoid 
flexure.  Variability  in  size  is  also  a  marked  character, 
and  at  one  examination  the  mass  may  appear  as  large  as 
the  closed  fist  or  even  two  fists,  and  the  next  day  it  appears 
not  larger  than  a  small  apple.  These  variations  are  due 
largely  to  the  presence  of  fsecal  masses  in  the  vicinity. 
Two  very  important  features  in  the  intestinal  tumor  may 
sometimes  be  detected  on  careful  palpation — namely,  the 
hardening  during  contraction  of  the  hypertrophied  wall  in 
the  vicinity  of  the  growth,  and  the  bubbling  of  gas  through 
the  tumor,  which  may  be  heard  as  well  as  felt.  This  latter 
feature  drew  our  attention  to  the  possibility  of  the  tumor 
n  Case  XLIV  being  associated  with  the  colon.  The  in- 
testinal symptoms  above  referred  to  and  a  progressive 
cachexia  are  generally  sufficient  to  warrant  a  diagnosis. 

II.  Omental  Tumors. — In  two  cases  a  rolled,  thick- 
ened omentum  formed  a  definite  tumor  in  the  upper  por- 
tion of  the  abdomen.  I  will  not  enter  into  full  details,  but 
just  mention  the  cases  in  abstract. 

Case  XL VI.  Pleuro-peri!:oneal  Tuberculosis;  Ridge-like  Tu- 
mor in  the  Epigastric  Region . — A  man,  aged  thirty  years,  admitted 
May  9, 1893,  with  ascites.  In  October  he  had  had  shortness  of  breath 
with  swelhng  of  the  legs  and  abdomen.  He  improved  gradually, 
but  the  ascites  has  persisted  and  on  admission  there  were  signs  also 
of  effusion  in  the  right  pleura.  In  the  abdomen  there  was  an  ill- 
defined  resistance,  a  hand's  breadth  in  width,  at  the  junction  of  the 
umbilical  and  epigastric  regions;  below  it  terminated  in  a  well-de- 
fined, hard  border,  which  could  be  very  easily  felt,  and  was  indeed 


133  THE   DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

at  first  thought  to  be  the  edge  of  the  liver.  On  percussion  there 
was  a  flat  tympany  above  the  hard  transverse  ridge.  There  was 
in  this  region  also  a  very  well  marked  peritoneal  friction  rub.  The 
history  of  the  case,  the  involvement  of  pleura  and  peritonaeum,  and 
the  existence  of  this  transversely  placed  tumor  mass  in  the  upper 
abdominal  zone  led  to  the  diagnosis  of  tuberculosis.  Dr.  Finney 
made  an  exploratory  operation  and  drained  the  peritonaeum.  The 
omentum  was  rolled  up,  thickened,  and  attached  to  the  transverse 
colon.  The  patient  did  well  and  was  discharged  from  the  hospital 
greatly  improved. 

Case  XLVII.  Chronic  Proliferative  Peritonitis;  Thickened 
Omentum.— In  this  patient  the  tumor  was  more  interesting  and 
unusual,  though  I  must  say  no  diagnosis  was  made.  I  refer  to  it 
especially  because  I  have  been  talking  to  you  so  much  in  the  ward 
class  about  chronic  proliferative  peritonitis  in  connection  with  the 
case  of  the  little  girl  with  a  visibly  pulsating  liver.  Without  going 
into  unnecessary  details,  the  patient,  aged  about  fifty-five  years, 
was  admitted  with  supptirative  cellulitis  of  the  left  leg  which  had 
come  on  in  connection  with  an  ascites  of  some  weeks'  duration. 
His  condition  was  very  serious,  and  one  for  which  we  could  not  do 
very  much.  He  gradually  sank,  and  died  ten  days  after  admission. 
The  abdomen  was  persistently  distended,  and  we  never  arrived  at  a 
definite  opinion  as  to  the  cause  of  the  dropsy.  The  parietal  perito- 
naeum was  adherent  to  the  anterior  surface  of  the  colon  and  to  the 
omentum  for  a  distance  of  3 "5  centimetres.  The  omentum  was 
represented  by  a  thick  fold,  seven  centimetres  in  vertical  by  nine- 
teen centimetres  in  transverse  extent,  the  upper  part  of  which  was 
converted  into  a  white,  shining,  leathery-like  structure,  not,  how- 
ever, rolled  or  curled  upon  itself.  Similar  thickenings  were  pres- 
ent over  the  anterior  surface  of  the  colon.  Tlie  intestines,  par- 
ticularly the  loops  of  small  bowel,  were  bound  together  by  dense 
adhesions,  separated  with  the  greatest  difficulty,  and  there  were 
patches  of  thickening  on  the  mesentery.  There  was  a  condition  of 
chronic  perisplenitis  and  perihepatitis.  There  was  a  thrombus  in 
the  portal  vein. 

As  in  the  clironic  tuberculous  peritonitis,  this  simple 
proliferative  form  may  pucker  the  omentum  into  a  defi.- 


TUMORS  OF  THE  PANCREAS.  I37 

nite  tumor,  lying  atliwart  the  upper  zone  of  the  abdomen. 
Encapsulated  exudate  may  also  form  tumor-like  masses. 
More  frequently,  however,  the  recurring  ascites  simulates 
cirrhosis  of  the  liver.  In  one  way  the  proliferative  perito- 
nitis may  produce  a  very  extraordinary  tumor,  of  which  I 
have  reported  an  example.*  So  great  may  he  the  thicken- 
ing of  the  mesentery  that  the  whole  bowel  is  shortened, 
and  the  coils  of  intestine  matted  together  may  form  a 
mass  the  size  of  a  cocoanut  firmly  bound  to  the  spine. 

III.  Tumors  of  the  Pancreas. — Two  cases  of  disease 
of  this  organ  came  before  me  for  diagnosis — one  a  cancer, 
the  other  possibly  a  cyst. 

The  cancer  case  you  will  remember,  as  I  demonstrated 
the  specimens  after  a  ward  class  early  in  the  session.  A 
reasonable  probability  may  sometimes  be  reached  in  the 
diagnosis.  The  following  may  be  mentioned  as  suggestive 
points :  Rapid  emaciation  with  early,  intense,  and  persist- 
ent jaundice ;  dilatation  of  the  gall  bladder,  fatty  stools, 
glycosuria,  salivation,  and  the  presence  of  a  tumor  be- 
tween the  umbilicus  and  ensiform  cartilage.  Nausea  and 
vomiting,  though  often  present,  are  variable  features.  Be- 
ginning usually  in  the  head  of  the  pancreas,  the  growth 
early  compresses  the  common  duct  and  causes  obstructive 
jaundice.  A  persistent,  intense  icterus  may  also  result 
from  compression  of  the  duct  in  the  gastro-hepatic 
omentum  by  infiltrated  glands,  secondary  to  cancer  of 
the  stomach,  to  invasion  of  the  ducts  themselves  by  can- 
cer, and  by  stenosis  of  the  common  duct,  rarely  by  gall- 
stones without  any  complication.  The  emaciation  is  rapid, 
and  stress  is  laid  by  some  writers  upon  an  excessive  ca- 
chexia. There  may  be  very  little  pain  throughout  the  ill- 
ness; in  some  cases,  however,  attacks  of  colic  occur.  A 
dilated  soft  gall  bladder,  while  not  in  itself  of  special  im- 

*  Tuberculous  Peritonitis,  Johns  Hopkins  Hospital  Reports,  vol.  ii. 


133  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

port,  is  often  suggestive,  taken  in  connection  with  other 
features.  In  the  primary  cancer  of  the  bile  passages, 
which  also  causes  an  early  and  intense  icterus,  the  gall 
bladder,  if  enlarged,  is  more  often  hard  and  firm.  Dis- 
turbance of  the  function  of  the  organ  may  be  manifest  by 
(l)  the  presence  of  fat  in  the  stools  (even  a  definite  stear- 
rhoea),  which  is  not  a  constant  symptom,  but  of  value 
when  present;  (2)  by  glycosuria,  which  is  also  not  con- 
stant. Salivation  is  sometimes  present,  and  Dr.  Lain^,  of 
Media,  has  called  my  attention  to  several  cases  in  which 
this  symptom  was  present,  and  in  which  the  diagnosis  of 
cancer  was  confirmed  by  autopsy. 

The  tumor  in  cancer  of  the  pancreas  is  not  always  to  be 
felt,  and,  as  in  Case  XLVIII,  there  may  be  ascites,  which 
renders  it  difficult.  The  mass  may  be  between  the  navel 
and  the  margin  of  the  right  lobe  of  the  liver,  as  in  our 
case.  It  is  deep  seated,  not  mobile,  variable  with  the  de- 
gree of  distention  of  the  stomach  and  intestines.  The  in- 
volvement of  the  adjacent  parts  may  give  to  it  the  charac- 
ters of  a  deep-seated,  dense,  massive  tumor.  Bear  in  mind 
that  in  very  thin-walled  persons,  particularly  in  women 
with  enteroptosis,  the  pancreas  can  be  felt  with  distinct- 
ness, but  the  conditions  are  very  exceptional  in  which  it 
could  be  mistaken  for  a  tumor. 

Case  XLVIII.  Intense  Jaundice ;  Progressive  Cachexia ;  As- 
cites ;  Tumor  in  Epigastric  Region. — E.  V.,  aged  thirty-four  years, 
admitted  to  "Ward  C,  October  24th,  complaining  of  dyspepsia  and 
jaundice.     Family  history  is  good. 

With  the  exception  of  chills  and  fever  fifteen  years  ago,  he  has 
been  a  very  healthy  man.  For  a  year  he  does  not  think  he  has 
been  in  his  usual  health,  feeling  tired  and  out  of  sorts ;  but  has  had 
no  nausea  and  no  vomiting.  For  about  two  months  he  has  been 
losing  rapidly  in  weight,  and  has  had  uncomfortable  sensations  in 
the  abdomen  after  eating.  A  month  ago  jaundice  developed,  and 
has  gradually  become  very  intense.     He  has  had  no  severe  pain. 


TUMOKS  OF  THE   PANCREAS.  139 

The  upper  part  of  the  abdomen  has  been  a  good  deal  swollen.  He 
came  to  hospital  on  account  of  the  jaundice,  weakness,  and  pro- 
gressive emaciation.  Patient  presented  all  the  characters  of  severe 
obstructive  jaundice.  He  is  much  emaciated;  skin  everywhere  of 
a  deep  yellow  color;  no  fever;  pulse,  76.  The  abdomen  is  dis- 
tended, particularly  in  the  upper  zone.  It  is  tympanitic  in  front  and 
dull  in  the  flanks,  with  well-marked  movable  dullness.  No  peri- 
stalsis seen  in  epigastric  region.  The  prominent  tympanitic  zone 
extends  as  low  as  the  umbilicus.  On  deep  pressure  in  the  right 
epigastric  region,  between  the  navel  and  the  costal  margin  there  is 
a  hard  nodular  mass,  difficult  to  outline,  owing  to  the  distention. 
There  is  enlargement  of  the  lymph  glands.  The  test  breakfast 
showed  the  presence  of  free  hydrochloric  acid,  and  the  stomach  did 
not  appear  to  be  dilated.  Examination  of  the  heart  and  lungs  was 
negative.  On  October  28th  and  on  November  1st  he  had  some 
stomach  distress,  for  which  lavage  was  practiced,  and  a  quantity  of 
dark,  coffee-ground-looking  material  was  washed  out.  On  Novem- 
ber 2d  it  was  noted  that  the  distention  in  this  case  was  unusual ;  no 
coils  were  to  be  seen ;  no  peristalsis.  The  tympany  extended  to  the 
fifth  rib  on  the  left  side,  and  a  little  above  the  costal  margin  on  the 
right  side.  The  stools  were  clay-colored,  rather  firm,  and  he  con- 
stantly had  to  take  purgative  mineral  waters.  Microscopically 
there  was  sometimes  a  good  deal  of  fat.  There  was  never  any 
sugar  in  the  urine,  which  had  the  usual  characters  of  this  secretion 
in  obstructive  jaundice. 

The  intensity  of  the  jaundice,  the  rapid  emaciation,  without  en- 
largement of  the  liver  or  recognizable  disease  of  the  stomach,  and 
the  presence  of  a  deep-seated  tumor  mass  led  to  the  suggestion  of 
pancreatic  disease.  The  tumor  was  difficult  to  feel  satisfactorily 
owing  to  the  very  great  distention  of  the  epigastric  region,  and  as 
the  patient's  physician  had  suggested  that  it  was  possibly  due  to 
gallstones,  and  as  he  was  himself  very  anxious  that  something 
should  be  done,  Dr.  Halsted  performed  an  exploratory  operation. 
More  fluid  was  found  in  the  peritonaeum  than  we  had  expected. 
The  remarkable  distention  in  the  epigastrium  was  due  to  the  float- 
ing up  on  the  top  of  the  fluid  of  the  colon  and  small  bowel.  The 
gall  bladder  was  found  to  be  dilated ;  but  the  mass  which  had  been 
felt  was  a  deep-seated  growth  in  the  situation  of  the  head  of  the 
15 


140 


THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 


pancreas.  The  patient  was  a  good  deal  relieved  by  the  operation, 
but  no  essential  change  took  place,  and  he  gradually  sank,  becom- 
ing very  intensely  emaciated,  and  died  November  18th. 

The  post-mortem  by  Dr.  Flexner  showed  the  head  and  body  of 
the  pancreas  to  be  the  seat  of  a  tumor  mass.  The  growth  had  infil- 
trated the  wall  of  the  duodenum,  and  the  posterior  wall  of  the 
stomach  was  involved  directly  from  the  tumor  in  an  area  eight 
centimetres  in  extent.  The  gall  bladder  and  ducts  were  much 
dilated  with  dark,  thick  bile. 

To  the  case  of  possible  cyst  of  the  pancreas  I  shall 
only  just  refer,  and  show  you  the  chart,  as  Dr.  Halsted, 
in  whose  practice  it  occurred,  will  publish  it  with  full 
details. 

The  man  (Case  XLIX),  aged  about  thirty  years,  was  admitted, 
April  14,  1893,  with  a  greatly  swollen  abdomen,  measuring  over 

forty  inches  in  circumference.  His 
illness  dated  from  January,  1890, 
when,  without  any  fall  or  injury, 
he  had  for  three  days  severe  colic, 
not  associated  with  vomiting  or  with 
jaundice.  A  month  later  he  had  a 
second  attack,  also  lasting  three  days; 
in  this  one  he  vomited,  and  noticed 
for  the  first  time  swelling  of  the  ab- 
domen. Then  the  attacks  recurred 
frequently,  two  or  three  a  month, 
each  time  with  nausea,  vomiting,  and 
colic,  and  the  abdomen  progressively 
enlarged  until  July,  1890,  after  which 
he  had  no  further  attacks  of  colic. 
The  abdomen  remained  large,  but  his 
general  condition  was  good  and  he 
was  able  to  do  light  work.  In  July 
1892,  he  fell  out  of  a  wagon,  jumped  up,  got  into  it  again,  but 
immediately  had  a  severe  attack  of  colic,  and  had  to  go  to  bed  in 
a  hotel  near  by  for  two  days.  He  had  nausea,  vomiting,  and 
great  pain.     The  swelling  gradually  disappeared,  and  in  ten  days 


Fig.  36.— a  cyst  in  the  abdomen, 
probably  of  the  pancreas  (Case 
XLIX). 


TUMORS  OF  THE   PANCREAS.  141 

the  girth  of  the  abdomen  decreased  from  forty-three  to  thirty-one 
inches.  He  had  profuse  diarrhoea,  but  he  does  not  think  there  was 
pus  or  blood  in  the  stools.  He  gained  in  weight  rapidly,  and  went 
to  work.  He  was  married  in  October,  and  remained  well  until 
January  of  this  year,  when  he  felt  his  trousers  were  tight  at  the 
waist  ;  and  during  the  past  three  months,  without  colic,  vomiting, 
or  jaundice,  the  abdomen  has  gradually  increased  in  size. 

A  truly  remarkable  history !  The  man  was  unusually  intelli- 
gent, and  insisted  that  his  statement  about  the  complete  disappear- 
ance of  the  tumor  after  the  fall  from  a  wagon  was  correct. 
When  he  came  under  observation  the  entire  abdomen  was  dis- 
tended, particularly  in  the  ujjper  zone  ;  the  ensiform  cartilage 
and  the  lower  ribs  were  everted.  The  distance  from  the  tip  of 
the  ensiform  cartilage  to  the  navel  was  21'5  centimetres  ;  from 
the  navel  to  the  pubes,  16 '5  centimetres.  The  wall  was  tense  and 
elastic ;  fluctuation  was  readily  obtained.  The  percussion  outlines 
are  given  in  the  chart.  There  was  resonance  only  in  the  epigas- 
tric angle,  in  the  hypochondriac  regions,  and  in  the  flanks.  In 
the  right  inguinal  region  there  was  an  elevated  ridge.  Dr.  Hal- 
sted  incised  and  drained  the  cyst,  which  was  found  adherent  to 
the  abdominal  wall.  Eighteen  litres  of  a  dark,  colfee-coJored  fluid 
were  removed,  which  was  alkaline  in  reaction,  contained  granular 
deb7Hs  and  much  altered  blood,  fresh  red  blood-corpuscles,  and  a 
few  large  cells  deeply  stained  with  blood  pigment. 

The  patient  had  a  tardy  convalescence,  but  ultimately- 
left  the  hospital  in  good  condition.  The  diagnosis  of  pan- 
creatic cyst  in  this  case  rests  rather  on  general  than  special 
grounds.  The  gradual  development  v^ith  attacks  of  colic, 
the  persistence  without  serious  damage  to  the  health,  th9 
disappearance  once  after  a  fall,  the  gradual  reaccumulation 
—all  point  to  a  retention  cyst.  There  were  no  features  point- 
ing to  loss  of  the  function  of  the  pancreas — neither  fatty 
stools  nor  glycosuria.  Large  pancreatic  cysts  may  fill,  as 
did  this  one,  the  entire  abdomen ;  in  long-standing  cases 
the  contents  consist,  as  a  rule,  of  altered  blood,  and  while 
an  amylolytic  ferment,  which  is  not  in  any  way  distinctive. 


14:2  THE  DIAGNOSIS  OP  ABDOMINAL  TUMORS. 

may  exist,  the  trypsin,  which  would  be  definite  and  conclu- 
sive, is  usually  not  present. 

Many  of  the  cases  described  as  cysts  of  the  pancreas 
are  really  instances  of  haemorrhage  into  the  lesser  perito- 
naeum. Let  me  refer  you  to  Mr.  Jordan  Lloyd's  suggestive 
and  timely  contribution.*  From  four  of  his  conclusions 
you  may  gather  the  gist  of  the  whole  matter. 

1.  "  That  contusions  of  the  upper  part  of  the  abdomen 
may  be  followed  by  the  development  of  a  tumor  in  the 
epigastric,  umbilical,  and  left  hypochondriac  regions." 

2.  "  That  such  tumors  may  be  due  to  fluid  accumula- 
tions in  the  lesser  peritoneal  cavity." 

3.  "  That,  when  the  contents  of  such  tumors  are  found 
to  have  the  property  of  rapidly  converting  starch  into 
sugar,  we  may  assume  that  the  pancreas  has  been  in- 
jured." 

4.  "  That  many  such  tumors  have  been  regarded  as  true 
retention  *  cysts  of  the  pancreas,'  and  that  this  opinion 
has  been  formed  upon  insufiicient  evidence." 

IV.  Miscellaneous  Tumors. — In  this  group  I  shall 
place  seven  cases,  in  two  of  which  the  diagnosis  was 
doubtful  or  could  not  be  definitely  made. 

(a)  A  Cyst  of  the  Abdomen  of  Unknown  Origin  (Mes- 
enteric).— The  following  case  presents  many  remarkable 
features.  For  more  than  two  years  he  has  had  recurring 
distention  of  the  abdomen,  which  reaches  such  a  size 
that  he  has  to  be  tapped.  With  the  exception  of  the 
period  of  onset,  from  October  to  December,  1891,  during 
which  he  lost  about  fifty  pounds  in  weight,  he  has  re- 
mained in  excellent  condition,  and  is  inconvenienced  only 
by  the  bulk  of  the  fluid  as  it  accumulates.  He  has  usually 
gone  to  work  the  day  after  the  tapping.  The  physical 
signs  are  those  of  a  cyst.    The  dullness  is  in  the  front  of 

*  British  Medical  Journal,  November  12, 1892. 


MISCELLANEOUS  TUMORS.  143 

the  abdomen,  with,  resonance  in  the  flanks.  He  was 
tapped  eight  times  in  1892,  and  five  times  up  to  date  this 
year.  The  quantity  removed  has  varied  from  one  gallon 
to  five  gallons  and  a  half.  At  the  last  two  tappings  the 
amount  has  been  only  a  gallon  and  a  gallon  and  a  half. 
At  first  the  fluid  was  dark  and  bloody,  but  since  the 
second  aspiration  it  has  been  a  turbid,  muddy-looking 
fluid,  alkaline  in  reaction,  containing  leucocytes  in  a  con- 
dition of  disintegration,  much  granular  and  molecular 
debris,  and  very  many  cholesterin  crystals.  I  regret  that 
no  chemical  examination  was  made  of  the  digestive  prop- 
erties of  the  sami:)le  of  the  fluid  which  was  sent  to  me. 
Dr.  Miller  has  reported  recently  that  the  patient  is  in  the 
best  of  health,  and  the  amount  of  fluid  is  gradually  di- 
minishing. 

Case  L.  Cyst  of  Doubtful  Orzgfm.— November  29,  1892.  I 
saw  to-day  the  following  very  unusual  and  remarkable  case  : 

X.  F.,  aged  forty-four  years.  Referred  to  me  by  Dr.  G.  B. 
Miller,  of  Philadelphia.  Patient  is  a  large-framed,  stout  man, 
looking  the  picture  of  health. 

Family  history  is  good.  His  personal  history  is  also  excellent. 
He  had  the  usual  diseases  of  childhood ;  scarlet  fever,  but  not  a 
very  severe  attack.  He  has  had  two  attacks  of  gonorrhoea;  has 
never  had  syphilis.  He  has  been  married  ten  years ;  no  children. 
He  uses  alcohol  moderately ;  has  never  been  a  heavy  drinker.  At 
times  during  the  past  six  or  eight  years  he  has  had  "  gouty  "  pains 
about  the  joints.  In  October,  1891,  he  noticed  that  he  was  get- 
ting uncomfortably  large  in  the  abdomen,  and  for  this  he  took 
three  bottles  of  some  "reduction  remedy,"  and  lost  in  weight 
everywhere  except  in  the  abdomen,  which  became  progressively 
enlarged.  He  then  consulted  Dr.  Loeling,  who  told  him  he  had 
fluid  in  the  abdomen.  He  kept  at  work,  however,  until  December, 
feeling  weak  and  having  occasional  attacks  of  nausea  and  vomit- 
ing. The  distention  of  the  abdomen  became  so  extreme,  in  spite 
of  active  catharsis  and  diuretics,  that,  on  December  26th,  he  was 
tapped  and  five  gallons  and  a  half  of  a  dark,  bloody  fluid  with 


144  THE  DIAGNOSIS  OF   ABDOMINAL  TUMORS, 

drawn.  An  examination  of  the  abdomen  after  removal  of  the 
fluid  failed  to  reveal  any  hardness,  tenderness,  or  tumor.  The 
urine  at  this  time  was  negative.  He  lost  in  weight  from  two 
hundred  and  fifty  pounds  to  two  hundred  and  two  pounds.  After 
the  first  tapping  he  gained  in  strength,  and  very  quickly  went  to 
his  business.  Gradually,  however,  throughout  January  the  fluid 
reaccumulated,  and  on  February  14,  1892,  he  was  again  tapped, 
and  three  gallons  of  dark,  bloody  fluid  removed.  Without  any 
aggravation  of  his  general  condition,  and  without  any  special  in- 
terference with  his  business,  the  fluid  continued  to  reaccumulate  at 
intervals,  and  he  was  tapped  on  the  following  dates  :  March  25th, 
five  gallons  and  a  quarter;  May  5th,  five  gallons  and  a  half  of 
dark  serum ;  June  12th,  one  gallon ;  June  22d,  dry  tapping,  no 
fluid  was  obtained;  July  9th,  twenty- eight  pounds;  August  12th, 
three  gallons  and  a  half  of  muddy,  turbid  fluid  ;  October  4th, 
twenty-six  pounds  of  turbid,  muddy  fluid;  November  22d,  last 
tapping,  three  gallons  removed.  He  has  felt  no  inconvenience 
from  the  tappings,  and  has  usually  resumed  work  on  the  fol- 
lowing day.  The  only  trouble  has  been  the  gradual  increase  in 
the  size  of  the  abdomen,  which  causes  shortness  of  breath  on  ex- 
ertion and  a  feeling  of  tension.  He  has  never  at  any  time  had 
swelling  of  the  feet  ;  the  bowels  have  been  regular ;  the  appetite 
has  been  lately  very  good,  and,  as  a  rule,  with  the  exception  of  a 
short  period  this  summer  when  he  got  pale  and  thin,  he  has  been 
in  very  good  health  and  has  been  able  to  attend  to  his  work  sys- 
tematically. 

Present  Condition.  — As  stated,  the  patient  is  a  large-framed, 
powerfully  built  man,  looking  the  picture  of  health.  The  color  is 
good  ;  the  venules  on  the  cheeks  are  somewhat  marked;  the 
tongue  is  clean;  the  pulse  is  quiet,  78  a  minute;  tension  moderate; 
no  sclerosis  of  the  arteries. 

The  abdomen  is  moderately  full,  but  not  larger  than  is  fre- 
quently seen  in  a  man  of  his  build.  It  is  symmetrical,  not  special- 
ly prominent  in  any  region.  The  pulsation  of  the  abdominal  aorta 
is  not  transmitted  to  the  surface;  respiratory  movements  of  the 
abdomen  are  natural.  There  is  no  special  enlargement  of  the  su- 
perficial veins.  The  inguinal  glands  are  not  enlarged.  On  palpa- 
tion it  is  everywhere  soft  and  painless.     No  tumor  masses  or  areas 


MISCELLANEOUS  TUMORS.  145 

of  specially  increased  resistance  are  to  be  felt.  On  deep  palpation 
below  the  right  costal  margin,  and  during  inspiration,  the  edge  of 
the  liver  can  be  touched.     Fluctuation  can  not  be  obtained. 

On  percussion  the  entire  front  of  the  abdomen  is  flat,  and  only 
on  the  deepest  percussion  in  the  region  of  the  navel  is  there  flat 
tympany.  The  dullness  continues  into  the  left  flank,  but  there  is  a 
flat  tympany  high  up  beneath  the  tenth  and  eleventh  ribs,  and  this 
is  continuous  in  the  left  hypochondriac  and  left  ej)igastric  areas 
with  the  stomach  tympany.  In  the  right  flank,  between  the  costal 
margin  and  the  ileum,  there  is  resonance.  On  turning  from  side 
to  side,  resonance  on  the  left  side  becomes  more  extensive,  that  on 
the  right  side  not  much  changed.  In  the  nipple  line  the  liver  dull- 
ness begins  at  the  lower  margin  of  the  sixth  rib,  and  there  is  no 
tympanitic  note  below  the  costal  margin.  The  flat  note  extends  to 
the  pubes.  In  the  erect  posture  there  is  tympany  in  the  epigastric 
and  left  hypochondriac  regions,  and  on  the  left  side  beneath  the 
lower  ribs. 

The  material  removed  at  the  last  tapping  was  turbid,  somewhat 
creamy  looking.  On  microscopical  examination  it  contains  nu- 
merous leucocytes  in  a  condition  of  disintegration,  larger  cells  in  a 
state  of  advanced  fatty  degeneration,  and  very  numerous  choles- 
terin  crystals. 

Of  course  the  first  thought  in  this  case  that  suggested 
itself  was  that  the  condition  was  an  anomalous  form  of 
ascites,  due  either  to  chronic  peritonitis  or  to  liver  disease. 
The  patient's  history,  the  absence  of  any  trace  of  jaundice, 
the  retention  of  general  nutrition,  and  the  absence  of  any 
evidences  on  examination  of  enlargement  or  contraction  of 
the  liver  seems  definitely  to  rule  out  hepatic  disease— cir- 
rhosis, perihepatitis,  or  tumor.  Nor  did  it  seem  likely  that 
any  of  the  known  forms  of  disease  of  the  peritonaeum  itself 
could  cause  recurring  ascites  without  serious  deterioration 
in  the  health,  tuberculosis,  cancer,  or  those  remarkable 
forms  of  epithelial  papillomata  involving  chiefly  the  omen- 
tum to  which  Lawson  Tait  refers. 

On  the  other  hand,  the  existence  at  first  of  a  bloody 


146  THE  DIAGNOSIS  OP  ABDOMINAL  TUMORS. 

fluid,  the  filling  of  the  abdomen  repeatedly  without  serious 
damage  to  the  health,  the  readiness  with  which  the  patient 
gets  up  and  goes  about  immediately  after  the  tapping,  the 
physical  examination,  the  presence  of  cholesterin  in  the 
fluid,  suggest  strongly  the  existence  of  cystic  disease,  either 
of  the  omentum  or  of  the  pancreas,  most  probably  of  the 
former. 

January  S6,  1893. — Patient  looks  in  robust  health.  Abdomen 
full,  but  not  so  much  as  at  former  visit.  Everywhere  soft,  but 
more  resistant  on  the  right  side;  and  on  deep  pressure  to  the  right 
of  and  a  little  above  the  navel  there  is  an  ill-deflned  mass.  No  defi- 
nite fluctuation  obtained.  Percussion  is  clear  in  epigastric  and 
upper  umbilical  region  and  to  the  left  side  shading  off  toward  the 
middle  of  Poupart's  ligament.  Dull  in  hypogastric,  right  iliac, 
right  lumbar,  and  right  half  of  umbilical,  and  when  he  turns  on 
the  left  side  the  dullness  persists  and  the  bowel  tympany  on  the 
left  side  is  exaggerated. 

Tapped  again  April  8,  1893,  and  only  fifteen  pounds  of  fluid  re- 
moved. He  was  tapped  Juae  17th,  three  fourths  of  a  gallon  re- 
moved ;  October  1st,  a  gallon  and  a  half ;  and  November  26th,  one 
gallon  removed. 

Additional  Note,  February,  1894. — He  had  been  doing  very 
well,  and  had  been  tapped  only  once  since  last  date.  One  Friday, 
during  a  business  trip,  he  felt  very  ill  on  the  train,  and  had  a  great 
deal  of  abdominal  pain  and  vomiting  that  night.  There  was  no 
very  special  distention  of  the  abdomen,  but  there  was  a  great  deal 
of  sensitiveness  on  palpation.  Attempts  were  made  in  various 
ways  to  move  the  bowels  without  any  effect.  On  Saturday  be  was 
very  much  worse,  and  seemed  collapsed  and  feeble.  There  were  a 
few  small  discbarges  from  the  bowels,  chiefly  of  blood.  There  was 
not  very  great  abdominal  distention.  He  had  vomiting  and  great 
depression,  which  increased,  and  he  died  on  the  Sunday  evening. 

Through  the  kindness  of  Dr.  Loeling  and  Dr.  Miller  I  was  noti- 
fied of  the  post-mortem  and  was  present.  The  body  was  that  of  a 
large-framed,  well -nourished  man.  The  panniculus  over  the  abdo- 
men was  at  least  two  inches  and  a  half  in  thickness.  There  was  no 
special  distention  of  the  abdomen. 


MISCELLANEOUS  TUMORS.  147 

PerilonEeum :  No  exudation,  serous  or  fibrinous.  In  the  right 
iliac  and  lumbar  regions  there  was  a  large  cyst,  the  anterior  wall 
of  which  was  adherent  in  several  places  to  the  abdominal  wall,  and 
in  addition  there  were  several  strong  bridles  of  adhesions,  one,  the 
longest,  from  the  left  side  of  the  cyst  to  the  peritonaeum  in  the 
neighborhood  of  the  left  crest  of  the  ilium.  Two  groups  of  fibrous 
bands  passed  from  the  left  cornu  of  the  cyst  to  the  abdominal 
wall,  just  to  the  left  of  the  navel.  There  were  also  one  or  two 
smaller  bands  of  adhesions,  and  at  one  point  the  upper  part  of  the 
jejunum  was  closely  adherent  to  the  top  of  the  cyst.  After  freely 
exposing  the  peritonaeum  by  a  crucial  incision  the  cyst  was  seen 
occupying  the  position  already  mentioned.  In  the  lumbar  region 
there  were  several  coils  of  the  small  intestine  which  had  passed 
beneath  the  bauds  of  adhesion,  uniting  the  left  cornu  of  the  cyst 
with  the  abdominal  wall  near  the  navel.  There  were  two  different 
loops  through  which  the  coils  of  intestine  had  passed ;  one  anterior, 
through  which  about  eight  inches  of  the  jejunum  had  passed  and 
the  intestine  was  only  slightly  reddened,  whereas  through  the  pos- 
terior loop  about  eighteen  inches  of  the  upper  part  of  the  ileum 
had  passed  and  had  become  strangulated.  The  coils  were  of  a  deep 
maroon  color,  swollen  and  infiltrated,  and  the  attached  portion  of 
the  mesentery  was  enormously  thickened  and  also  plum-colored. 
The  peritonaeum  over  these  strangulated  coils  was  smooth,  there 
was  no  fibrinous  exudate,  and  they  could  be  withdrawn  without 
any  difficulty  through  the  snare. 

The  intestines  were  then  removed  as  far  as  a  foot  above  the  ileo- 
caecal  valve.  They  presented  nothing  of  note  except  in  the  stran- 
gulated portion  just  described.  After  their  removal  the  position  of 
the  cyst  could  be  clearly  determined.  It  was  of  about  the  size  of  a 
man's  head,  occupied  the  right  iliac  and  right  lumbar  regions,  and 
extended  to  the  left  beyond  the  middle  line.  It  lay  directly  upon 
the  spine  and  on  the  lumbar  and  iliac  muscles  on  the  right  side. 
The  hand  could  be  placed  beneath  it,  and  it  could  be  lifted  readily 
from  its  bed.  The  lower  foot  of  the  ileum  was  closely  attached  to 
its  left  and  lower  margin ;  below  was  the  caecum,  and  the  appendix 
formed  a  long,  flattened,  cord-like  structure  passing  up  its  posterior 
wall.  The  ascending  colon  lay  along  its  right  side.  The  tumor 
lay  in  the  mesentery  of  the  last  foot  or  eighteen  inches  of  the 


148  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

ileum,  and  it  was  removed  very  readily  by  stripping  tlie  ascending 
colon  and  caecum  from  its  attachment  to  the  peritonaeum.  The  sac 
had  a  grayish- white  appearance,  except  at  its  left  side,  where  it  was 
stained  of  a  greenish  color.  There  were  no  other  adhesions  except 
those  mentioned  to  the  parietal  peritonaeum  and  to  the  jejunum. 
It  was  a  little  roughened  and  puckered  in  places.  When  it  was 
laid  open,  the  fluid  was  a  little  turbid  and  slightly  blood-stained. 

(6)  Multiple  Tumor  Masses  in  Abdomen;  Phantom  Tumor. 
Case  LI. — Mrs.  E.,  aged  fifty -two  years,  admitted  June  8,  1893, 
complaining  of  a  swelling  below  the  right  jaw,  pain  in  the  abdo- 
men, and  of  having  vomited  blood.  There  is  nothing  of  note  in 
her  family  history. 

She  has  had  eight  children;  four  are  living.  She  has  never 
been  a  very  strong  woman.  Fourteen  years  ago  she  had  a  sub- 
mucous uterine  fibroid,  which  was  removed.  Twenty-eight  years 
ago  she  had  a  severe  attack  of  typhoid  fever.  In  October  of  1891 
she  had  diphtheria,  which  was  followed,  she  says,  by  a  lump  at  the 
angle  of  the  right  jaw.  Shortly  after  this,  too,  she  began  to  have 
occasional  pains  in  the  abdomen.  In  October,  1892,  after  a  period 
of  a  good  deal  of  excitement  and  worry,  she  had  what  was  called 
brain  fever,  and  was  \inconscious  for  two  weeks.  She  was  in  bed 
at  this  time  for  nearly  three  months,  partly  in  consequence  of  a 
carbuncle  on  the  back. 

She  dates  her  present  illness  from  about  February  of  this  year, 
when  she  had  a  great  deal  of  oppression  after  eating,  sometimes 
nausea,  which  were  unusual  symptoms.  She  also  had  at  times 
straining  at  stool  and  a  desire  to  go  very  frequently.  The  dyspep- 
tic symptoms  increased,  though  she  never  had  severe  pain.  Four 
weeks  ago,  after  a  day  or  two  of  much  dyspeptic  trouble,  she  had 
an  attack  of  vomiting  after  breakfast,  and  brought  up  a  large 
amount  of  black,  clotted  blood.  Her  appetite  has  been  poor,  and 
she  has  had  a  great  deal  of  eructation  and  pain  after  eating,  re- 
lieved sometimes  by  the  use  of  soda.  For  a  week  before  her  ad- 
mission the  right  foot  began  to  swell.  Within  the  past  six  months 
a  tumor  mass  has  developed  below  the  right  jaw.  Her  condition 
on  admission  was  as  follows  :  Much  emaciated;  sallow  complexion. 
Attached  in  front  of  the  angle  of  the  right  lower  maxilla  is  a 
group  of  enlarged  glands,  which  extend  over  the  jawbone  on  the 


MISCELLANEOUS   TUMORS.  149 

cheek.  The  whole  mass  can  be  readily  moved ;  the  skin  is  a  little 
reddened ;  the  individual  glands  can  be  felt.  The  supraclavicular 
glands  are  not  enlarged.  The  abdomen  looks  a  little  full.  The 
right  epigastric  vein  is  much  distended  with  blood ;  the  left  vein 
not  quite  so  large.  The  current  in  both  is  from  below  upward. 
In  the  epigastric  region  to  the  left  of  the  navel  several  nodular 
masses  can  be  seen  beneath  the  skin.  There  is  no  peristalsis  visible. 
On  palpation  to  the  left  of  the  navel,  there  is  a  solid,  somewhat 
cord-like  mass,  about  six  centimetres  in  length,  which  extends  in 
an  oblique  direction  toward  the  axilla.  It  is  very  firm  and  hard, 
superficial,  and  feels  as  if  attached  to  something  beneath,  as  it  is 
only  partially  movable.  No  gas  is  felt  bubbling  in  it.  Just  above 
and  to  the  right  of  the  navel  is  a  firm  mass  which  is  more  difficult 
to  limit  and  define.  Midway  between  the  navel  and  the  ensiform 
cartilage  is  a  soft,  button-like  mass  which  at  intervals  projects  be- 
neath the  skin,  and  then  suddenly  relaxes  with  a  sizzling  sound. 
In  a  few  moments  it  appears,  hardens  into  an  ovoid,  resistant  body 
about  three  centimetres  in  lateral  ^extent,  and  then  relaxes  again 
with  a  sound  of  gas  bubbling  in  it.  The  right  inguinal  region  is 
occupied  by  a  large  nodulated  mass  feeling  like  a  collection  of 
lymph  glands.  The  left  inguinal  glands  are  somewhat  enlarged. 
She  had  no  diarrhoea;  the  stools  were  liquid,  grayish-brown  in 
color.     The  rectal  examination  was  negative. 

The  patient  remained  under  observation  for  two  weeks,  and  no 
essential  change  took  place  in  the  condition.  There  was  no  dilata- 
tion of  the  stomach.  The  tumor  masses  above  described  were  very 
evident. 

She  left  the  hospital  on  June  30th,  unimproved. 

In  many  respects  no  case  in  the  series  was  more  inter- 
esting than  this  one,  but  a  definite  conclusion  as  to  the  seat 
of  the  primary  disease  did  not  seem  possible.  Naturally, 
with  dyspepsia,  belching,  loss  of  appetite,  and  progressive 
emaciation,  one  suspected  the  stomach  to  be  the  seat  of  the 
malady,  the  more  so  with  an  account  of  an  attack  of  vom- 
iting in  which  she  brought  up  a  large  amount  of  clotted 
blood.  While  under  observation  in  hospital,  the  condition 
was  not  such  as  to  justify  putting  her  to  the  worry  of  a 


150  THE  DIAGNOSIS  OP  ABDOMINAL  TUMORS. 

test  breakfast.  Not  one  of  the  tumors  in  tlie  abdomen 
was  apparently  connected  with  the  stomach  itself,  nor 
were  there  signs  of  dilatation.  The  tumors  were  rather 
like  masses  of  enlarged  lymph  glands.  The  enlargement 
of  the  glands  in  the  right  side  of  the  neck  dated,  she  in- 
sists, from  the  diphtheria  in  October,  1891,  but  they  had 
enlarged  very  much  since  February.  The  supraclavicular 
glands  were  not  especially  enlarged.  Altogether  we  in- 
clined to  the  opinion  that  there  was  a  new  growth  in  the 
stomach  with  extensive  secondary  lymphatic  infection. 
By  far  the  most  striking  feature  in  the  case  was  the  phan- 
tom tumor  appearing  and  disappearing  midway  between 
the  navel  and  the  ensiform  cartilage.  Every  minute  or 
two  it  would  emerge  beneath  the  skin  like  a  button,  get 
firm  and  hard,  assume  an  ovoid  shape,  and  then,  as  one 
watched  it,  relax  and  disappear  with  a  sizzling  noise, 
which  could  be  heard  as  well  as  felt.  Of  course  such  a 
tumor  is  only  felt  in  connection  with  the  tubular  muscle 
of  the  gastro-intestinal  canal,  and  in  this  case  it  was  in 
all  probability  a  limited  portion  of  the  coat  hypertrophied 
on  the  proximal  side  of  constriction,  caused  either  by 
a  new  growth  at  the  attachment  of  the  mesentery,  or  by 
some  narrowing  neoplasm  in  the  wall  itself.  There  was 
admitted  yesterday  to  the  ward  a  case  in  which  you  can 
study  another  remarkable  phantom  muscle  tumor.  The 
young  man  has  a  well-marked  history  of  ulcer,  with  vom- 
iting of  blood  and  hyperacidity  of  the  gastric  juice.  The 
stomach  is  somewhat  dilated,  and  in  the  epigastric  region 
there  appears  at  intervals,  readily  seen  beneath  the  skin, 
an  ovoid  tumor,  four  to  five  centimetres  in  length,  which 
lifts  the  abdominal  wall  definitely,  and  then  in  a  few  mo- 
ments relaxes  and  disappears.  "When  visible  it  is  very 
firm  and  hard,  and  when  relaxed  it  can  only  just  be  felt. 

(c)  Uterine  Fibroids. — It  speaks  well  for  the  differentia- 
tion of  the  cases  in  the  hospital  that,  so  far  as  I  know,  the 


MISCELLANEOUS  TUMORS.  151 

following  is  the  only  instance  of  tumor  associated  with  the 
female  pelvic  organs  which  came  before  me  for  examina- 
tion. This,  too,  was  rather  by  accident.  As  she  had  tu- 
berculosis of  the  lip  and  tongue,  the  question  was  raised 
whether  the  abdominal  condition  was  not  due  also  to 
tuberculosis : 

Case  LII.  Tuberculosis  of  the  Lip  and  Cheek;  Multiple  Tu- 
mors in  the  Abdomen. — The  patient,  aged  about  forty  years,  was 
admitted  for  tuberculosis  of  the  lip,  tongue,  and  cheek.  The  abdo- 
men was  distended,  and  I  was  asked  to  see  her  to  determine  the 
nature  of  the  masses  which  could  be  felt.  She  stated  that  they 
had  been  present  for  many  years,  and  had  never  given  her  any 
trouble.  The  characters  were  very  definite.  The  lumbar,  iliac,  the 
greater  part  of  the  umbilical,  and  the  entire  hypogastric  regions 
were  occupied  by  solid  masses,  which  in  the  iliac  regions  presented 
several  rounded  movable  prominences.  The  uterus  was  firmly 
fixed,  and  the  whole  pelvis  appeared  blocked  with  the  masses.  One 
point  only  was  of  interest  in  connection  with  the  difi'erential  diag- 
nosis of  tuberculous  peritonitis.  In  the  iliac  regions  palpation 
was  much  softer,  and  the  areas  of  resistance  were  separated  by  dis- 
tinct intervals,  and  only  on  deep  pressure  could  solid,  uniform 
masses  be  felt.  On  percussion,  there  was  a  flat  tympany,  such  as 
one  finds  not  infrequently  when  tuberculous  tumors  are  scattered 
about  among  the  coils  of  intestines.  Here  the  history,  the  charac- 
ter of  the  masses,  and  the  persistence  for  more  than  a  dozen  years 
were  quite  sufficient  for  the  diagnosis. 

{d)  Sarcoma  of  the  Abdominal  Wall. — The  following 
case  is  uncommon  in  my  experience  and  is  worth  placing 
on  record.  Not  only  was  there  a  large,  massive,  subcu- 
taneous tumor  in  the  lower  umbilical  and  upper  hypogas- 
tric regions,  but  there  were  secondary  nodules  beneath 
the  skin  of  the  other  parts  of  the  body. 

Case  LIII.  Sarcoma  of  the  Abdominal  Wall;  Numerous 
Subcutaneous  Metastases. — Mrs.  A.,  aged  fifty-two  years.  The 
patient  had  been  a  healthy  woman,  had  worked  hard,  and  brought 
up  a  large  family.     For  two  months  previous  to  my  consultation 


152  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

with  Dr.  Atherton,  of  Toronto,  Au^st  24th,  she  had  suffered  with 
diarrhoea  and  attacks  of  dyspepsia.  The  frequent  movements  have 
persisted.  There  was  considerahle  nausea  during  last  month,  and 
vomiting  occurred  frequently  after  eating  or  drinking.  She  said 
she  felt  full,  and  could  not  hold  much  in  the  stomach.  Within 
the  past  two  months  she  had  lost  flesh  rapidly  and  had  become 
very  weak.  When  first  seen  by  Dr.  Atherton,  August  9th,  the 
tumor  about  to  be  described  was  present.  The  examination  by 
him  of  the  pelvic  viscera  was  negative.  There  was  no  cancer 
of  the  breast. 

The  patient  was  a  medium-sized  woman ;  looked  emaciated, 
scarcely  cachectic;  was  somewhat  pale;  tongue  furred.  Nothing 
of  special  moment  about  the  circulatory  or  respiratory  systems. 
The  pulse  was  a  little  rapid,  but  of  fair  volume,  somewhat  irregu- 
lar. Slight  cough  and  some  bloody  expectoration,  which  con- 
tinued until  her  death. 

On  exposing  the  abdomen  there  was  seen  a  remarkable  con- 
dition of  the  abdominal  walls.  While  the  portion  above  the  navel 
looked  normal,  below  this  point  there  was  a  large  mass  occupying 
the  lower  umbilical,  the  whole  of  the  hypogastric  region,  and  ex- 
tending into  the  inguinal  regions.  The  skin  was  not  discolored 
and  showed  the  lineae  albicantes. 

On  superficial  inspection  it  might  have  been  taken  for  a  some- 
what unusual  localized  development  of  the  fatty  panniculus.  On 
palpation  the  mass  was  felt  to  be  firm,  hard,  involving  the  skin 
(which  could  not  be  moved  separately),  and  presented  a  curious 
nodular  feel,  suggestive  rather  of  bunches  of  lymph  glands,  or  of 
the  sensation  given  by  touching  the  lobulated  kidney  of  a  sheep. 
With  this  there  was  also  a  feeling  of  massiveness  and  solidity,  as 
if  the  tumor  extended  through  the  subcutaneous  tissues.  The 
mass  sloped,  as  it  were,  gradually  toward  the  periphery,  and  here 
the  nodules  were  more  isolated,  and  in  lines  running  obliquely 
toward  the  false  ribs.  There  were  chains  of  these  little  nodules, 
like  lymph-knots.  The  whole  surface  of  the  body  seemed  tender 
and  painful  on  palpation.  She  complained  bitterly  of  pain  after 
much  handling  of  the  mass.  There  were  nodules  also  beneath 
the  skin  of  the  right  breast,  one  or  two  in  the  right  thigh,  and 
several  in  other  parts. 


MISCELLANEOUS  TUMORS.  153 

Dr.  Atherton  writes  that  he  saw  her  for  the  last  time  on  Sep- 
tember 3d,  and  that  she  died  on  September  17th,  The  daughter 
states  that  diarrhoea  and  vomiting  continued,  but  no  blood  was 
passed  at  any  time.  For  a  few  days  before  death  "  blue  lumps," 
of  about  the  size  of  a  small  bean,  appeared  in  various  parts  of  the 
trunk  and  extremities,  which  were  tender  and  painful,  like  those 
seen  by  us. 

Whether  or  not  this  growth  was  primary  in  the  ab- 
dominal walls  is  impossible  to  say  in  the  absence  of  details 
which  could  be  furnished  by  the  autopsy  alone.  She  had 
had  gastro-intestinal  trouble,  but  not  such,  as  pointed  to 
malignant  disease  of  stomach  or  bowel. 

(e)  Tumors  of  Doubtful  Nature. — In  none  of  the  follow- 
ing cases  did  it  seem  possible  to  arrive  at  a  satisfactory 
diagnosis.     The  salient  points  are  as  follows : 

Case  LIV.  Dysentery ;  Two  Tumor  Masses  in  Abdomen. — 
Samuel  T,,  aged  about  forty  years,  seen  with  Dr.  F.  E.  Smith, 
November  17,  1892,  complaining  of  a  lump  in  the  abdomen  and 
diarrhoea.  His  general  health  has  been  excellent,  and  his  family 
history  is  good.  He  had  typhoid  fever  when  nine  years  of  age. 
Ten  years  ago  he  was  caught  between  two  cars  and  injured  about 
the  hips  and  legs.  He  was  laid  up  at  this  time  for  four  months 
and  had  a  dull  pain  in  the  right  side,  which  has  recurred  at  in- 
tervals, but  never  prevented  him  from  working.  Two  months  ago 
he  appears  to  have  had  an  attack  of  acute  dysentery,  frequent 
passages,  and  swelling  of  the  legs.  He  was  in  bed  for  six  weeks. 
As  late  as  October  17th  of  this  year  he  passed  blood  in  the  stools. 
He  now  has  no  swelHng  in  the  legs;  appetite  is  good;  bowels 
regular;  and  he  has  gained  in  weight  and  looks  well,  perhaps  a 
little  sallow.  He  has  had  no  fever ;  tongue  is  clean.  No  enlarge- 
ment of  the  lymph  glands.  In  the  right  upper  quadrant  of  the 
umbilical  region,  extending  into  the  adjacent  hypochondriac  and 
lumbar  regions,  there  is  a  firm,  resistant  mass,  which  reaches  to 
about  two  centimetres  below  the  level  of  the  navel,  and  to  the 
right  can  be  felt  as  far  out  as  the  tip  of  the  tenth  rib.  To  the  left 
it  does  not  quite  reach  to  the  middle  line.     On  bimanual  palpation 


154 


THE  DIAGNOSIS  OF  ABDOMINAL   TUMORS. 


it  is  freely  movable.  It  is  not  well  felt  below  the  ribs  behind,  but 
on  deep  pressure  it  can  be  pushed  forward,  and  then  is  distinctly 
movable.  It  can  be  readily  separated  above  from  the  liver,  the 
edge  of  which  is  easily  to  be  felt.  In  the  hypogastric  region,  just 
above  the  pubes,  and  to  the  right  of  the  middle  line,  there  is  a 
second  tumor,  feeling  about  the  size  of  an  orange,  somewhat 
elongated.     To  the  right  it  appears  to  have  a  definite  ridge-like 

edge.  The  percussion  is  everywhere 
resonant,  and  a  clear  note  is  elicited 
over  both  tumors,  except  for  a  short 
space  to  the  right  of  the  middle  line 
over  the  one  in  the  hypogastric  re- 
gion. Neither  spleen  nor  liver  dull- 
ness is  increased.  There  is  no  dilata- 
tion of  the  stomach.  The  urine  is 
clear  and  he  has  passed  no  blood,  and 
there  is  no  albumin ;  no  tube  casts. 

The  patient  was  seen  again  Jan- 
uary 10th.  General  condition  has 
been  excellent,  and  he  has  been  at 
work.  There  is  no  cachexia.  The 
tumor  masses  previously  noted  were 
present  with  great  distinctness.  The 
lower  one  appeared  to  be  scarcely  so 
large  as  on  previous  examination. 
In  the  left  inguinal  region,  about  three  centimetres  from  Poupart's 
ligament,  there  is  a  freely  movable,  subcutaneous  nodular  body 
about  the  size  of  a  bean.     The  inguinal  glands  are  not  enlarged. 

It  did  not  seem  possible  to  arrive  at  any  conclusion  as 
to  the  nature  of  these  tumors.  The  strongest  possibility- 
seemed  to  be  of  their  connection  with,  the  intestine,  as  he 
had  tenesmus,  diarrhoea,  and  melsena,  but  the  patient's 
excellent  general  condition  and  rapid  improvement  would 
seem  to  contraindicate  new  growth. 

While  preparing  this  lecture  for  the  press  this  patient 
was  seen  (December  20th).  His  condition  remains  excel- 
lent and  he  has  been  steadily  at  work.    The  lower  tumor 


Fig.  37.— Situation  of  the  tumors  in 
Case  LIV. 


MISCELLANEOUS  TUMORS.  155 

is  no  longer  palpable ;  tlie  upper  is  still  quite  distinct, 
though  smaller  than  at  date  of  former  note.  Its  position 
is  unchanged. 

The  following  case  I  regarded  at  first  as  tumor  of  the 
stomach,  but  on  subsequent  examination  it  seems  to  be  ex- 
tremely doubtful  whether  it  is  really  in  this  organ : 

Case  LV.  Tumor  Mass  in  the  Epigastrium  of  Doubtful  Na- 
ture.— Kate  H.,  aged  forty-one  years,  admitted  August  29,  1893, 
complaining  of  pain  in  the  left  side  and  swelling  in  the  epigas 
trium.  There  is  nothing  of  moment  in  the  family  history.  She 
has  been  healthy  with  the  exception  of  typhoid  fever  at  twenty- 
one  and  pleurisy  last  winter.  She  has  had  at  times  irregular 
cramps  in  the  abdomen.  For  several  years  she  has  had  dyspep- 
sia, suffering  with  belching  after  eating  and  slight  discomfort. 
Ten  months  ago  she  had  an  attack  of  severe  pain  in  the  epigas- 
trium, with  nausea  and  vomiting,  and  was  in  bed  for  a  week.  In 
the  next  two  mouths  she  had  four  similar  attacks,  which  lasted 
about  a  week.  Some  of  these  attacks,  the  doctor  said,  were  due  to 
gallstones.  About  two  months  ago  she  first  noticed  the  swelling 
in  the  abdomen  which  is  now  present.  She  does  not  think  it  has 
increased  in  size.  She  never  has  been  jaundiced ;  bowels  are  regu- 
lar ;  passes  a  normal  quantity  of  urine.  Her  chief  complaint  is  of 
a  dull  pain  below  the  left  costal  margin.  She  is  a  fairly  well- 
nourished  woman ;  lips  and  mucous  membranes  are  pale;  tongue 
is  coated.  The  abdomen  is  distended,  chiefly  in  the  epigastrium 
and  in  the  right  hypochondriac  region,  in  which  there  is  a  smooth 
prominence.  On  palpation  this  corresponds  to  a  rounded,  hard- 
ened, somewhat  nodular  tumor,  which  in  the  middle  line  feels  quite 
smooth  and  on  the  right  side  is  more  irregular.  In  the  nipple  line 
there  is  a  marked  ridge  to  be  felt  midway  between  the  costal  mar- 
gin and  the  transverse  navel  line.  The  liver  dullness  begins  at  the 
sixth  rib,  and  continues  directly  into  this  prominent  tumor  mass. 
At  first  it  was  thought  that  this  represented  an  enlarged  Uver,  but 
on  September  2d,  on  palpation,  gurgling  sounds  were  noted  "in  the 
prominent  tumor  in  the  epigastrium,  and  to-day  it  is  everywhere 
resonant.     The  gurgling  can  be  felt  in  this  solid  mass  with  the 

greatest  distinctness.     The  tympany  reaches  as  high  as  the  base  of 
16 


156  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

the  ensiform  cartilage."  Ewald's  test  breakfast  showed  the  pres- 
ence of  free  hydrochloric  acid.  This  case  interested  us  extremely 
from  the  remarkable  simulation  of  the  outline  of  the  tumor  mass 
to  that  of  an  enlarged  liver. 

On  September  5th  the  following  note  was  made :  "  There  is  a 
very  distinct  prominence  below  the  costal  margin  in  right  epigas- 
tric and  right  hypochondriac  regions.  On  palpation,  a  firm,  re- 
sistant mass  fills  the  upper  zone  of  the  abdomen,  the  outline  of 
which  resembles  quite  accurately  that  of  an  enlarged  liver.  Be- 
yond the  left  parasternal  line  no  very  distinct  edge  is  to  be  felt, 
but  toward  the  right,  as  she  draws  a  deep  breath,  there  is  a  distinct 
nodular  edge.  The  entire  mass  descends  with  inspiration.  The 
resonance  is  not  so  extensive  to-day,  it  does  not  reach  beyond  the 
right  parasternal  line.  After  inflation  the  stomach  tympany  ex- 
tends two  fingers'  breadth  below  the  navel,  and  there  is  in  the  left 
epigastric  and  the  left  upper  quadrant  of  the  umbilical  region  the 
outline  of  a  dilated  stomach. 

When  resonance  was  first  noticed  in  the  mass  below  the  ensi- 
form cartilage  we  thought  that  possibly  extensive  infiltration  of 
the  stomach  wall  existed ;  but  the  patient  has  been  under  observa- 
tion on  several  occasions  since,  and  she  has  gained  in  weight,  looks 
well,  free  hydrochloric  acid  is  present  in  the  gastric  juice,  and  after 
inflation  the  resonance  is  not  more  tympanitic,  and  the  stomach 
outlines  seem  somewhat  below  the  mass.  Altogether  there  was 
doubt  enough  to  exclude  the  case  from  the  stomach  list,  and  I  place 
it  here  among  the  miscellaneous  tumors  of  doubtful  nature. 

(/)  Aneurysm  of  the  Aorta. — And  lastly,  not  the  least 
interesting  of  the  miscellaneous  tumors  was  a  large  saccu- 
lated aneurysm  of  the  abdominal  aorta. 

Case  LVI. — Lee  K.,  aged  sixty-seven  years,  admitted  July  5th, 
complaining  of  a  "  fluttering  lump  "  in  the  abdomen.  With  the 
exception  of  scurvy  and  rheumatism  during  the  civil  war  he  has 
been  a  very  healthy  man.  He  is  temperate  and  denies  venereal 
disease,  but  there  is  a  distinct  cicatrix  just  beyond  the  glans  penis. 

Present  Illness. — For  three  years  he  has  noticed  a  lump  in  the 
abdomen,  which  for  the  past  two  years  has  been  painful,  and  which 
he  says  has  lately  increased  in  size.     He  has  a  dull,  steady,  gnawing 


MISCELLANEOUS  TUMORS,  157 

pain  in  tlie  tumor  itself,  and  more  or  leps  pain  in  the  back.  The 
pain  and  throbbing  sometimes  nauseate  him,  particularly  after  eat- 
ing, and  he  has  vomited  twice  in  the  past  two  weeks.  Bowels  are 
constipated;  he  has  severe  headaches,  and  has  had  occasional  bleed- 
ing from  the  nose.  He  is  short  of  breath  on  exertion.  Patient  is  a 
very  vigorous,  healthy- looking  man;  well  built;  well  nourished; 
musculature  above  the  average.  The  conjunctivae  are  a  little 
watery  and  yellow;  pupils  are  equal.  Pulse  regular,  equal  in  both 
radials;  the  arteries  thickened;  can  be  rolled  under  the  finger; 
pulse  wave  can  not  be  obliterated.  The  brachial  arteries  are  tor- 
tuous. The  examination  of  the  lungs  is  negative.  The  apex  beat 
of  the  heart  is  seen  in  the  fifth  interspace,  just  outside  the  nipple 
line;  it  is  forcible  and  well  defined.  The  sounds  are  clear;  the 
first  a  little  thudding,  and  both  somewhat  accentuated  at  the  base. 

Abdomen. — In  the  epigastric  and  upper  part  of  the  umbilical 
regions  there  is  an  irregularly  rounded  prominence,  which  pulsates 
forcibly  and  almost  synchronously  with  the  heart  impulse.  It  has 
a  transverse  diameter  of  8'5  centimetres;  vertical  nearly  eight  cen- 
timetres. It  is  perhaps  a  little  more  prominent  to  the  right  than  to 
the  left  of  the  middle  line,  and  on  the  right  side  almost  obliterates 
the  groove  below  the  right  costal  margin.  On  palpation  it  feels 
smooth,  yields  to  firm  pressure,  expands  forcibly  and  in  all  direc- 
tions. There  is  at  times  a  distinct  systolic  thrill.  The  borders  are 
everywhere  rounded  and  it  seems  to  dip  down  rather  sharply  just 
above  the  umbilicus.  The  tumor  is  not  influenced  by  the  knee- 
elbow  position.  The  whole  mass  can  be  grasped  in  the  hand  and 
the  expansion  in  that  way  very  readily  felt.  It  is  unusually 
mobile  laterally.  It  can  be  moved  to  the  right,  so  that  its  left 
border  is  at  the  middle  line.  It  can  not  be  moved  to  the  left 
quite  so  far,  but  far  enough  so  that  it  pulsates  under  the  left 
costal  margin.  The  up  and  down  movements  are  very  slight ;  it 
is  not  influenced  by  respiration.  There  is  dullness  on  light  per- 
cussion over  the  top  of  the  mass,  and  in  a  circle  the  diameter 
of  which  would  be  five  centimetres.  Beyond  this  there  is  tym- 
pany on  all  sides.  On  auscultation  there  is  a  loud  systolic  bruit 
heard  everywhere  over  the  tumor.  There  is  no  definite  diastolic 
shock.  The  condition  of  the  liver,  spleen,  and  other  parts  of  the 
abdomen  is  negative.    The  diagnosis  of  aneurysm  of  the  abdominal 


158 


THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 


aorta  was  made  by  Dr.  Hewetson,  under  whose  care  the  patient  first 

came,  and  subsequently  when  I  saw  him  the  doubt  arose  in  my 

mind,  owing  to  the  extreme  mobility, 
whether  it  was  really  in  the  aorta,  or 
whether  it  might  not  be  connected 
with  one  of  the  branches — the  tumor 
seemed  remarkably  mobile,  and  could 
be  pushed  so  far  from  left  to  right. 
Dr.  Halsted,  too,  thought  that  the  tu- 
mor might  possibly  be  in  one  of  the 
branches ;  and  as  the  patient  con- 
sented he  did  an  exploratory  opera- 
tion. The  tumor  was  found  to  spring 
directly  from  the  aorta  just  above  the 
renal  arteries.  The  pedicle  of  the  sac 
was  short  and  almost  as  wide  as  the 
aneurysm  itseK.  It  was  thought  bet- 
ter to  leave  the  case  to  Nature  than  to 
attempt  any  measures  to  promote  con- 
solidation   in  the  sac.      The  patient 

recovered  rapidly  from  the  operation  and  left  the  hospital  in  about 

ten  days. 


Fig.  38.— Position  of  the  aneurysm. 
The  dotted  outlines  illustrate  the 
extreme  mobility.    Case  LVI. 


Aneurysm  of  the  abdominal  aorta  is  rare.  This  is  the 
first  one  which  has  been  under  our  observation  since  the 
hospital  was  opened,  during  which  time  there  have  been 
between  forty  and  fifty  aneurysms  of  the  thoracic  aorta 
in  the  wards.  The  diagnosis  here  was  readily  made  ;  the 
tumor  was  so  pronounced,  so  rotund,  so  expansile  in  all 
directions,  and  with  a  well-marked  thrill  and  systolic 
bruit — no  single  feature  of  aneurysm  was  absent.  The 
mobility  alone  was  unusual ;  not  one  of  the  few  aneurysms 
in  this  situation  which  I  have  seen  presented  such  remark- 
able mobility. 

A  few  weeks  subsequently  I  saw  in  Montreal  with  Dr. 
Shepherd  a  patient  who  had  progressive  ansemia  and  de- 
bility with  great  abdominal  distention  and  pain.    An  ab- 


MISCELLANEOUS  TUMORS.  159 

domiual  tumor  had  been  suspected,  but  the  tympany  and 
distention  of  the  stomach  and  bowels  prevented  any  satis- 
factory examination.  She  became  more  ansemic  and  died 
the  day  after  I  saw  her.  Through  the  kindness  of  Dr. 
Wyatt  Johnston,  I  saw  the  specimen,  which  proved  to  be 
a  large  aneurysm  of  the  abdominal  aorta  which  had  com- 
pressed the  duodenum,  causing  great  dilatation  of  the 
stomach.  It  had  ruptured  at  one  edge  and  haemorrhage 
had  taken  place  into  the  retroperitoneal  tissues. 


LECTURE  VI. 

TUMORS   OF   THE   KIDNEY.* 

Nowhere  is  the  close  interdependence  of  medicine  and 
surgery  better  illustrated  than  in  the  diagnosis  and  treat- 
ment of  tumors  of  the  kidney.  A  very  large  proportion 
of  the  cases  come  first  under  the  care  of  the  physician, 
whose  province  it  is  to  recognize  the  condition  ;  but  to  do 
justice  to  his  patient  he  should  be  thoroughly  familiar 
"with  the  advances  which  have  been  made  in  the  depart- 
ment of  renal  surgery.  Let  me  first  call  your  attention 
to  the  diagnosis  of  certain  conditions  associated  with — 

1.  Movable  Kidney,  (a)  Errors  in  the  Diagnosis  of 
Movable  Kidney. — I  have  no  statistics  to  offer  with  refer- 
ence to  the  frequency  of  movable  kidney,  but  throughout 
the  session  you  have  had  many  opportunities  of  noting  its 
commonness — so  common,  indeed,  that  we  are  never  with- 
out examples  in  the  wards.  A  majority  of  the  cases  pre- 
sent no  symptoms  whatever.  Others  complain  much  of 
dragging  pains  in  the  back,  with  neuralgia,  epigastric  dis- 
tress, and  general  nervousness ;  many  of  neurasthenia  with 
dyspepsia ;  and  one  often  finds,  particularly  in  women 
who  have  borne  children,  the  condition  to  which  Gldnard 
has  given  the  name  enteroptosis.  In  a  thin  person,  male 
or  female,  who  presents  the  general  features  of  neurasthe- 
nia, you  will  be  almost  certain  to  find,  on  examination,  mo- 
bility of  one  or  other,  or  of  both  the  kidneys.     Inability  to 

*  Concluding  lecture  of  the  course.     Delivered  Dec.  26,  1893. 

160 


TUMORS  OF  THE  KIDNEY.  161 

lie  comfortably  on  the  left  side,  and  paroxysmal  attacks 
of  pain  such  as  I  shall  describe  in  a  few  moments,  are  less 
frequent  symptoms.  It  is  difficult  really  to  determine  how- 
far  all  these  features  are  dependent  on  the  renal  condition. 
It  is  quite  possible  that  the  pains  and  uneasy  feelings  may 
be  due  to  stretching  and  tension  of  the  tissues  in  the  neigh- 
borhood of  the  great  abdominal  nerve  plexuses ;  but  one 
not  infrequently  meets  with  cases  of  the  most  extreme  mo- 
bility without  any  symptoms  whatever.  It  may  be  that,  in 
persons  with  a  debilitated  and  bankrupt  nervous  system, 
the  tension  caused  by  the  dragging  of  a  movable  kidney 
may  be  at  once  felt,  just  as  many  persons  find  the  first  in- 
dication of  physical  fagging  in  subjective  sensations  of  the 
movement  of  the  heart,  of  which  in  health  we  are  not  cog- 
nizant. The  text-books  and  monographs  now  contain  a 
full  and  satisfactory  account  of  the  condition,  but  I  wish 
to  call  your  attention  to  some  less  widely  recognized  fea- 
tures in  connection  with  it. 

While  in  the  great  majority  of  all  cases  movable  kid- 
ney is  quite  unmistakable,  there  are  cases  in  which  its 
recognition  is  by  no  means  easy.  You  will  remember  that 
in  Case  V  we  made  a  somewhat  serious  faux  pas,  and 
thought  that  an  unusually  mobile  pyloric  tumor  was  a 
movable  kidney.  A  more  frequent  error  is  the  mistaking 
of  it  for  a  dilated  gall  bladder.  I  have  already  alluded  to 
this,  and  in  Lecture  IV  have  spoken  of  the  points  to  be 
attended  to  in  the  diagnosis.  Here  I  may  mention  a  case 
of  a  good  deal  of  interest  in  which  this  error  was  made, 
and  the  operation  for  dilated  gall  bladder  performed  by 
Mr.  Tait.  The  patient,  a  doctor  from  California,  consulted 
me  in  1888  about  a  lump  in  the  abdomen,  the  nature  of 
which  had  puzzled  a  large  number  of  physicians.  It  had 
been  present  for  ten  or  eleven  years,  and  had  appeared 
first  after  a  somewhat  severe  attack  of  sea- sickness.  He 
had  suffered  a  great  deal  with  nervous  troubles  and  dys- 


1G2  THE  DIAGNOSIS  OP  ABDOMINAL  TUMORS. 

pepsia,  and  when  I  saw  him  there  were  signs  of  dilatation  of 
the  stomach.  The  position,  mobility,  and  general  charac- 
ters made  me  feel  tolerably  certain  that  the  tumor  was  a 
movable  right  kidney,  and  with  this  opinion  the  late  Dr. 
Agnew  coincided.  The  diagnosis  relieved  his  mind  very 
much,  and  he  improved,  so  far  as  nervous  symptoms  were 
concerned.  Subsequently  he  grew  worse,  and  in  the  spring 
of  1890  he  consulted  Mr.  Tait,  who  diagnosticated  dilated 
gall  bladder,  and  made  an  exploratory  incision.  The  gall 
bladder  was  normal,  and  the  kidney,  so  he  stated,  was  in 
situ.  Subsequently  the  patient  came  under  the  care  of  Dr. 
C.  O.  Baker,  of  Auburn,  N.  Y.,  who  found  the  tumor  very 
evident,  made  a  diagnosis  of  floating  kidney,  and  per- 
formed nephrorrhaphy,  with  great  relief  to  the  patient. 
The  case  is  reported  in  the  Medical  Record  for  May  14, 
1892.  The  patient  died  in  September  of  this  year  (1893)  of 
empyema,  and  in  the  post-mortem  notes,  which  were  very 
kindly  sent  to  me,  the  statement  about  the  kidney  is : 
"  Right  organ  in  normal  position,  held  by  firm  union ; 
nephrorrhaphy  had  been  performed  for  floating  kidney." 
There  is  no  mention  made  of  enlargement  of  the  gall 
bladder. 

With  very  pendulous  and  lax  abdominal  walls  and  an 
unusually  mobile  right  kidney  there  may  be  at  first  diffi- 
culty in  separating  clearly  the  right  lobe  of  the  liver  and 
the  kidney.     In  the  following  case  I  was  at  first  in  doubt : 

Case  LVII.  Movable  Kidney,  simulating  a  Local  Growth  in 
the  Right  Flank ;  Right  Lobe  of  Liver  mistaken  for  Right 
Kidney.— Jane  E.  G.,  aged  fifty -two  years,  seen  with  Dr.  Hewet- 
son,  in  the  Medical  Dispensary,  September  25, 1892,  complaining  of 
cough  and  pains  in  the  back  and  side  and  headache.  She  is  pale 
and  somewhat  emaciated,  and  looks  ill.  Lips  and  mucous  mem- 
branes are,  however,  of  a  good  red  color.  She  has  borne  nine 
children.  She  has  lost  in  weight  during  the  past  six  months. 
There  are  no  abnormal  physical  signs  in  the  thorax.     In  the  ex- 


TUMORS  OF  THE  KIDNEY.  163 

amination  of  the  abdoraen  there  was  detected  a  solid,  mobile  tumor 
in  the  right  side,  which  was  not  thought  to  be  the  kidney,  as  it  was 
believed  that  this  organ  could  be  also  felt  in  the  flank.  On  the 
examination  I  found  a  well-marked,  readily  movable  tumor,  just 
at  the  right  of  the  navel,  and,  on  bimanual  palpation,  the  right 
kidney  could,  I  thought,  also  be  felt.  The  left  kidney  was  readily 
palpable.  As  I  was  unable  to  satisfy  myself  as  to  the  nature  of  the 
mass,  I  asked  to  see  her  again  on  the  28th. 

Examination. — Patient  is  thin ;  not  cachectic.  The  abdomen  is 
pendulous,  and  the  walls  are  very  lax.  On  the  right  side,  a  little 
above  the  line  drawn  from  the  anterior  superior  spine  to  the  navel, 
a  movable  tumor  can  be  felt,  somewhat  rounded  in  shape,  about 
the  size  of  an  orange,  not  distinctly  reniform,  but  with  a  slight 
depression  on  the  right  side.  It  can  be  pushed  up,  but  not  entirely, 
beneath  the  ribs,  and  it  does  not  slip  into  position  like  a  floating 
kidney.  Below  it  can  be  pushed  down  so  as  partially  to  pass  the 
line  joining  the  anterior  superior  spines.  To  the  left  it  can  be 
pushed  over  to  the  middle  line.  It  is  not  painful.  Examination 
of  the  right  renal  region  showed  a  depression  below  the  ribs  be- 
hind, but,  on  bimanual  palpation,  the  flank  appeared  to  be  filled 
with  a  solid  mass.  Careful  examination,  however,  determined 
that  this  was  not,  as  suspected  on  the  first  examination,  the  kidney, 
but  in  reality  part  of  the  right  lobe  of  the  liver,  the  ligaments  of 
which  were  much  relaxed.  An  edge  could  be  distinctly  felt ;  to 
the  right  the  lobe  was  ill-defined,  and  it  could  not  be  made  to  slip 
up  in  the  way  so  characteristic  of  movable  kidney.  On  the  left 
side  the  kidney  was  readily  palpable,  and,  on  deep  inspiration, 
depressed  so  much  that  the  fingers  could  almost  be  inserted  above 
the  upper  border. 

I  have  no  doubt  that  in  this  case  the  tumor  in  the 
right  side  of  the  abdomen  was  the  kidney,  and  that  the 
mass  felt  in  the  right  flank  represented  in  reality  the 
right  lobe  of  the  liver. 

Among  the  scores  of  cases  of  movable  kidney  which 
have  come  under  my  observation  I  do  not  remember  one 
in  which  the  condition  was  exactly  as  presented  in  this 
patient.    At  the  first  examination  I  felt  sure  that  a  kidney 


164  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

was  palpable  in  the  renal  region,  but  the  more  careful 
subsequent  examination  convinced  me  that  I  had  been  in 
error. 

I  have  already  called  your  attention  to  the  elongation 
of  the  edge  of  the  right  lobe  of  the  liver  as  a  cause  of  an 
anomalous  tumor  mass  in  the  right  flank,  and  mentioned 
the  case  in  which  laparotomy  was  performed  by  Dr.  Kelly 
for  an  obscure  tumor,  which  proved  to  be  the  thinned-out 
edge  of  the  right  lobe. 

In  the  following  case  I  erred  in  thinking  that  a  tumor 
in  the  right  side  of  the  abdomen  was  a  dislocated  and  fixed 
kidney : 

Case  LVIII.  Tumor  in  Bight  Side  supposed  to  he  a  Dislocated 
and  Fixed  Kidney;  Gradual  Disappearance. — Mrs.  H.  O.,  seen 
December  9,  1892,  with  Dr.  Arthur  Wilhams,  of  Elkridge,  Md. 

I  saw  this  patient  first  in  October,  1891,  when  she  consulted  me 
for  pains  in  the  abdomen.  She  had  always  been  in  good  health  as 
a  girl  ;  had  been  married  twelve  years  ;  had  four  children,  the 
youngest  three  years  of  age.  Six  months  ago  she  began  to  have 
pain  in  the  abdomen,  chiefly  in  the  epigastric  region,  and  radiating 
to  the  back  and  to  the  chest.  She  has  never  had  any  vomiting, 
nor  is  the  pain  connected  with  the  taking  of  food.  Within  this 
period  of  time  she  has  lost  about  sixteen  pounds  in  weight.  A  few 
months  ago  she  noticed  a  lump  in  the  abdomen,  which  has  caused 
her  great  uneasiness,  and  it  was  for  the  purpose  of  determining  the 
nature  of  this  that  Dr.  Williams  advised  a  consultation. 

Examination. — She  was  a  thin,  dark-complexioned  woman, 
neither  anaemic  nor  cachectic.  The  abdomen  was  distended,  uni- 
form, with  normal  respiratory  movements.  On  palpation  not 
tender,  not  sensitive,  and  nothing  was  felt  except  at  the  boundary 
of  the  epigastric  and  umbilical  regions  on  the  right  side,  where  an 
elongated  tumor  occupied  exactly  the  extension  of  the  parasternal 
line.  The  lower  end  was  rounded  and  smooth,  and  reached  a  little 
below  the  level  of  the  navel.  The  upper  end  was  not  palpable. 
To  the  left  the  mass  did  not  extend  beyond  the  middle  line.  The 
right  margin  was  rounded  and  well-defined  ;  the  left  a  little  de- 


TUMORS  OF  THE  KIDNEY.  165 

pressed  and  irregular.  It  was  not  very  movable,  but  by  using 
both  bands  it  could  be  sbifted  slightly  from  side  to  side.  The  sur- 
face was  smooth  ;  it  was  a  little  sensitive  to  pressure,  and  felt  very 
resistant  and  solid.  The  fingers  could  be  placed  directly  beneath 
the  lower  end,  but  it  did  not  appear  to  have  an  ovoid  or  globular 
outline.  No  gas  was  felt  to  pass  through  it  after  repeated  examina- 
tions. The  stomach  was  not  dilated.  The  kidney  could  not  be  felt 
on  either  side.  The  urine  was  normal  and  the  bowels  were  regu- 
lar. She  had  no  attacks  of  colic,  and  the  pains  which  she  described 
were  not  specially  suggestive  of  biliary  colic.  I  noted  at  the  time 
that  the  case  was  somewhat  puzzling.  The  tumor  had  the  situation 
rather  of  a  pyloric  growth,  though  its  long  axis  was  vertical,  but 
there  had  been  no  dyspepsia,  and  there  was  no  dilatation  of  the 
stomach.  The  situation  was  somewhat  suggestive  of  the  gall 
bladder,  though  it  seemed  to  have  more  resistance  than  a  tumor 
caused  by  dilatation  of  this  organ.  It  had  an  outline  very  suggest- 
ive of  renal  tumor,  and  I  was  rather  inclined  to  regard  it  as  a 
dislocated  and  fixed  kidney.  I  gave  the  patient  every  encourage- 
ment and  assured  her  that  it  was  not  a  malignant  growth.  At  my 
request  the  patient  returned  on  December  9, 1892.  To  my  astonish- 
ment the  tumor  had  disappeared  entirely  ;  not  a  trace  of  it  could  be 
felt.  Examination  of  the  abdomen  was  absolutely  negative.  The 
right  kidney  was  not  palpable  ;  the  gall  bladder  could  not  be  felt ; 
the  edge  of  the  liver  could  be  just  touched  during  deep  inspiration. 
The  patient  stated  that  she  had  improved  very  much.  The  pains 
had  diminished,  and  she  now  had  very  little  distress.  She  had 
gained  in  weight,  and  was  on  the  whole  very  much  better.  Here, 
in  all  probability,  I  had  mistaken  a  dilated  gall  bladder  for  a  mov- 
able kidney.  The  tumor  was  scarcely  large  enough,  and  had  not 
the  situation  of  intermittent  hydronephrosis,  the  only  other  one 
which  could  disappear  in  this  way. 

(b)  DieU's  Crises  in  Movable  Kidney.— B^emaT^ahle  at- 
tacks of  pain  occur  in  connection  with  movable  kidney, 
to  which  attention  was  first  called  by  Dietl.  A  knowledge 
of  the  existence  of  these  renal  crises,  as  they  have  been 
termed,  is  very  important,  and  as  they  form  a  very  strik- 
ing feature  in  certain  cases  of  movable  kidney,  I  propose 


106  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

to  call  yoTir  attention  to  them  at  some  length.  The  text- 
books, with  the  exception  of  the  last  edition  of  Flint's, 
have  been  curiously  silent  regarding  this  symptom  group. 
In  Dietl's  paper,  which  appeared  in  the  Wiener  medicin- 
ische  WochenscJirift,  1864,  nine  cases  of  movable  kidney 
are  reported,  all  of  which  had  pains  in  the  side  and  back. 
In  four  there  were  also  attacks  of  nausea  and  vomiting, 
with  great  pain,  swelling,  and  tenderness  of  the  affected 
kidney.  These  were  liable  to  recur,  particularly  on  exer- 
tion. Dietl  was  doubtful  about  the  pathology  of  the  con- 
dition, but  from  the  title  of  the  paper,  Wandernde  Nieren 
und  deren  Einklemmung,  it  is  evident  that  he  regarded  it 
as  a  strangulation  caused  probably  by  a  twist  in  the 
vessels. 

The  case  which  first  called  my  attention  to  the  condi- 
tion was  a  patient  of  the  late  Dr.  Palmer  Howard's,  of 
Montreal. 

A  lady,  aged  about  forty  years,  stout  and  well  nourished,  began 
some  months  after  her  third  pregnancy  to  have  violent  attacks 
of  pain  in  the  abdomen,  in  which  she  became  nauseated,  often 
vomited,  and  suffered  so  intensely  that  hypodermics  of  morphine 
alone  gave  relief.  She  was  seen  by  the  late  Dr.  George  W,  Camp- 
bell, who  discovered  a  lump  in  the  right  side  of  the  abdomen.  The 
attacks  recurred  with  great  severity  throughout  the  winter  of 
1879-80.  The  patient  lost  in  weight  and  the  diagnosis  of  a  new 
growth  was  made.  In  the  spring  of  1880  she  consulted  in  New 
York  the  late  Dr.  Austin  Flint,  who  agreed  with  Dr.  Howard  and 
Dr.  Campbell  as  to  the  very  serious  nature  of  the  case.  Through- 
out the  year  the  attacks  recurred,  and  she  lost  in  weight  from  one 
hundred  and  seventy  to  one  hundred  and  twenty  pounds.  In  the 
spring  of  1881  she  again  went  to  New  York  and  consulted  Flint 
and  Van  Buren.  As  she  was  at  this  time  very  much  thinner,  a 
more  satisfactory  examination  of  the  abdomen  could  be  made. 
Van  Buren  at  once  suggested  that  the  tumor  was  a  movable  kid- 
ney, with  which  he  stated  that  he  had  frequently  met  with  parox- 
ysmal attacks  of  severe  pain,  particularly  in  gouty  persons.     He 


TUMORS  OF  THE   KIDNEY.  167 

advised  a  very  strict  diet.  The  relief  of  mind  was  naturally  very 
great,  and  the  patient  began  at  once  to  improve,  gaining  rapidly  in 
weight.  The  paroxysms  reduced  in  frequency,  and  for  years  she 
remained  well,  having  at  intervals,  particularly  if  she  committed 
any  indiscretion  in  diet,  recurrences  of  the  severe  pain. 

The  following  cases  have  been  recently  under  observa- 
tion: 

Case  LIX.  Enteroptosis ;  Movable  Right  Kidney;  Severe 
Renal  Crises. — Susan  S.,  aged  forty-six  years,  admitted  January 
13, 1893,  complaining  of  agonizing  pain  in  the  abdomen  and  back, 
and  a  lump  in  the  right  side.  She  was  married  at  twenty-three  ; 
has  had  nine  children,  no  miscarriages  ;  menopause  two  years  ago. 
Of  late  years  she  has  been  very  nervous  and  is  often  irritable  and 
depressed.  At  the  time  of  the  menopause  she  had  pains  in  the 
back,  and  once  the  head  was  drawn  to  one  side  for  a  few  days. 
Until  two  years  ago  the  pains  were  of  a  dull  aching  character,  but 
at  this  time  she  noticed  a  lump  in  the  right  side,  and  the  pains 
became  much  more  intense.  The  attacks  now  come  on  without 
warning  and  are  so  severe  that  she  becomes  helpless.  They  last 
for  several  hours,  and  though  she  never  loses  consciousness,  they 
are  so  agonizing  that  for  a  time  she  can  not  speak.  On  two  or 
three  occasions  she  has  fallen  down.  She  gets  cold,  sweats  a  good 
deal,  feels  nauseated,  but  has  never  vomited.  The  pain  is  chiefly 
in  the  right  side,  and  the  lump  becomes,  she  says,  sensitive  and 
larger.  The  attacks  have  recurred  every  two  or  three  months. 
The  last  one  was  four  weeks  ago.  On  several  occasions  after  very 
severe  attacks  the  urine  has  been  dark-colored.  She  has  never  had 
jaundice.  The  patient  is  a  well-nourished  woman  ;  lips  and  mu- 
cous membranes  of  good  color  ;  temperature  normal  ;  examination 
of  heart  and  lungs  negative. 

The  abdominal  walls  are  greatly  relaxed,  and  the  much-scarred 
skin  can  be  grasped  in  large  folds.  On  the  left  side  the  kidney  can 
be  felt  readily  on  deep  inspiration.  On  the  right  side,  extending 
outward  to  within  3*5  centimetres  of  the  middle  line,  and  down- 
ward at  least  8 "5  centimetres  from  the  costal  margin,  is  a  smooth, 
rounded  mass,  very  freely  movable  to  the  right.  It  is  superficial 
and  seems  to  emerge  directly  beneath  the  ribs.     It  descends  with 


168  THE  DIAGNOSIS  OP  ABDOMINAL  TUMORS. 

inspiration,  and  when  the  patient  turns  on  the  left  side,  falls  far 
over  beyond  the  middle  line,  and  can  be  lifted  with  the  fingers 
beneath  it.  It  is  smooth  on  the  surface,  and  as  stated  seems  to 
emerge  directly  from  beneath  the  costal  margin.  To  the  left  it  can 
be  felt  beyond  the  middle  line.  The  lower  edge  is  rounded,  but  the 
fingers  can  not  be  placed  beneath  it.  It  is  evident  that  this  mass  is 
a  depressed  and  somewhat  freely  movable  liver.  On  bimanual 
palpation,  deep  pressure  opposite  the  point  of  the  tenth  rib,  the 
right  kidney  can  be  readily  felt  behind  and  separate  from  the 
liver,  and  on  deep  inspiration  it  moves  down  and  can  be  readly 
grasped. 

We  had  a  good  deal  of  discussion  about  the  nature  of  this  large 
flat  mass  in  the  right  flank.  It  felt  very  superficial,  smooth,  and 
we  thought  at  first  it  might  be  an  enlarged  and  movable  kidney, 
but  repeated  examination  seemed  to  indicate  that  it  was  the  liver, 
somewhat  movable  and  tilted  forward,  owing  to  the  relaxed  condi- 
tion of  the  abdominal  wall.  The  following  note  was  made  on  the 
19th  :  When  the  patient  lies  on  the  left  side  the  hepatic  fiatness 
does  not  begin  in  the  anterior  axillary  line  until  the  ninth  rib  ; 
when  on  her  back  it  begins  at  the  eighth.  In  the  nipple  line,  when 
she  is  on  her  back,  the  flatness  begins  at  the  seventh  rib,  and  ap- 
parently falls  an  inch  lower  when  she  is  on  her  left  side.  The 
border  of  the  mass  can  be  felt  more  distinctly  in  the  nipple  line, 
and  suggests,  taking  into  consideration  the  fact  that  one  feels  below 
it  the  kidney  sliding  backward,  while  near  the  umbilicus  there  is  a 
sharp  border,  the  existence  both  of  a  movable  kidney  and  a  mov- 
able liver. 

The  patient  remained  in  hospital  for  nearly  four  weeks  and 
gained  in  weight.  She  was  greatly  relieved  by  our  statement  as  to 
the  nature  of  her  case.  She  had  no  attack  of  severe  pain  while 
under  observation.  The  character  of  the  attacks  suggests  the  renal 
crises  common  in  floating  kidney. 

The  following  case  is,  I  believe,  a  very  typical  instance  , 
of  Dietl's  crises,  and  is  interesting  also  from  the  protracted 
course  and  the  intensity  of  the  recurrences  : 

Case  LX.  Movable  Kidney;  Renal  Crises  at  Intervals  for 
Seven   Yeai^s. — Dr.  X.,  aged   forty -three    years,  seen    October  18, 


TUMORS  OP  TPIE  KIDNEY.  IQQ 

1893,  complaining  of  attacks  of  agonizing  pains  in  the  abdomen, 
which  have  recurred  on  and  off  for  seven  years.  The  patient  has 
been  a  very  healthy  man,  of  good  habits,  and  has  for  twenty  years 
been  engaged  in  a  very  laborious  country  practice.  At  the  time  of 
the  onset  there  was  a  great  deal  of  typhoid  fever  in  bis  district,  the 
roads  were  very  bad,  and  for  seven  weeks  he  was  in  the  saddle  con- 
stantly. The  first  attack,  which  was  of  a  very  agonizing  character, 
came  on  when  he  was  very  much  fatigued,  and  was  so  severe  that 
he  nearly  fainted  and  required  morphine.  He  had  no  vomiting 
and  did  not  pass  any  blood  in  the  urine.  Since  that  time  the 
attacks  have  recurred,  sometimes  two  or  three  in  a  week,  sometimes 
only  one  in  six  or  eight  weeks.  He  has  never  vomited  in  them, 
though  sometimes  the  intensity  of  the  pain  makes  him  nauseated. 
The  bowels  are  regular  and  he  has  never  had  jaundice.  He  never 
can  tell  exactly  when  the  attack  will  come  on.  It  usually  begins 
abruptly  and  the  intensity  of  the  pain  is  such  that  he  often  has  to 
take  chloroform.  The  attacks  last  from  a  few  hours  to  the  greater 
part  of  a  day,  and,  in  passing  away,  leave  him  a  little  exhausted  and 
with  a  feeling  of  soreness  and  aching.  The  pain  is  most  intense 
in  the  right  flank  and  extends  toward  the  navel  and  to  the  spine. 
He  does  not  think  that  any  tumor  develops  at  the  time,  but  the 
muscles  of  the  abdomen  are  tightly  contracted  and  the  right  flank 
is  sensitive.  He  has  noticed  in  very  many  of  the  attacks  that  he 
micturates  freely,  and  the  amount  of  urine  is  increased  as  the 
attacks  pass'  off.  There  never  has  been  any  change  in  the  charac- 
ter of  the  urine. 

The  patient  is  a  moderately  well-built  man ;  looks  healthy  and 
strong;  tongue  is  clean.  The  abdomen  is  soft,  flat;  no  sensitive- 
ness over  the  stomach;  the  pylorus  is  not  palpable;  the  edge  of  the 
liver  can  be  felt  just  below  the  costal  margin ;  it  is  not  sensitive. 
The  spleen  can  not  be  felt. 

The  right  kidney  is  readily  palpable,  and,  when  he  draws  a  deep 
breath,  comes  down  so  low  that  the  fingers  can  easily  be  slipped 
above  it  and  fix  it  below  the  level  of  the  tenth  rib.  It  is  a  little 
sensitive  on  pressure,  but  is  not  apparently  enlarged.  When  he 
turns  on  the  left  side  the  kidney  falls  forward  and  can  be  also 
readily  felt  just  below  the  margin  of  the  liver.  The  left  kidney  is 
not  palpable. 


170  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

These  renal  crises  constitute  perhaps  the  most  distressing 
symptoms  of  movable  kidney,  and  they  are,  I  think,  very 
much  more  common  than  we  are  led  to  suppose.  The 
knowledge'  of  their  existence  is  important,  as  the  attack 
may  be  so  severe  as  to  simulate  peritonitis.  The  cause  of 
the  symptoms  is  not  at  all  clear.  The  terms  which  have 
been  used,  Einklemmung  by  the  Germans,  and  etrangle- 
ment  by  the  French,  are  based  upon  the  view  originally  ex- 
pressed by  Dietl,  that  it  was  a  condition  of  strangulation 
or  extreme  engorgement  caused  by  a  twist  in  the  vessels  of 
the  floating  kidney.  Dietl  thought  that  about  the  moving 
organ  there  was  a  local  peritonitis.  The  explanation  which 
passes  current  at  present  is  more  reasonable,  namely,  that 
the  condition  is  due  to  a  kink  or  twist  in  the  upper  part  of 
the  ureter,  with  retention  of  the  urine  in  the  pelvis  and 
calices,  and  a  production  of  a  transient  hydronephrosis,  the 
severe,  agonizing  pain  being  caused  by  the  distention  of 
the  tissues. 

II.  Intermittent  Hydronephrosis. — With  the  excep- 
tion of  a  remarkable  case  of  the  rare  congenital  form,  upon 
which  my  colleague  Halsted  operated  in  this  hospital  three 
years  ago,  I  had  never  seen — to  recognize — a  case  of  inter- 
mittent hydronephrosis.  During  the  present  session  three 
examples  have  come  under  my  notice.  Let  me  first  read  to 
you  the  notes  of  the  cases : 

Case  LXI.  Intermittent  Development  of  Large  Tumor  on  the 
Left  Side. — Mrs.  F.,  aged  forty-three  years,  seen  with  Dr.  Finney, 
September  9,  1893,  complaining  of  trouble  in  the  left  side.  She  has 
been  a  healthy  woman ;  has  had  four  children ;  never  has  had  any 
trouble  after  her  confinements,  and  she  does  not  think  that  she  was 
unusually  large  during  her  pregnancies.  She  has,  on  the  whole, 
enjoyed  very  good  health.  In  April  last  she  stumbled  over  a  slop  jar 
and  wrenched  her  back,  but  she  did  not  feel  it  much  at  the  time. 
Early  in  May  she  had  the  fii'st  severe  attack  of  pain  in  the  left  side, 
which  Dr.  Archer,  who  attended  her,  thought  was  renal  colic. 


TUMORS  OF  THE  KIDNEY. 


171 


There  were  three  paroxysms — at  3,  6,  and  9  P.  M.  They  were  evi- 
dently veiy  severe,  as  she  was  bent  over  with  the  pain  and  had 
severe  vomiting.  The  urine  was  not  bloody,  and  in  a  few  days  she 
was  herself  again,  but  one  evening  she  was  surprised  to  feel  a 
"  lump  "  in  the  left  side,  which  has  been  present  at  intervals  ever 
since.  It  has  not  been  especially  painful,  but  is  a  little  uncomfort- 
able, and  associated  with  a  feeling  of  distention  and  uneasiness,  par- 
ticularly when  she  is  lying  down.  It  is  not  more  painful  after  eat- 
ing, nor  has  diet  any  special  influence.  She  has  not  lost  in  weight. 
She  is  quite  positive  that  the  lump  in  the  side  appears  and  disap- 
pears ;  thus,  she  says,  she  could  not  feel  it  on  the  5th  and  6th  of  this 
month,  and  she  thinks  that  throughout  the  greater  part  of  July  it 
was  not  present.  Its  onset  is  always  ushered  in  with  pain  in  the 
left  side,  but  the  attacks  have  never  been  so  severe  as  those  which 
she  had  in  May.  She  has  noticed  on  several  occasions  that  she  has 
voided  large  quantities  of  urine,  as  much  as  five  pints  between  8  P.  M. 
and  six  o'  clock  the  next  morning, 
usually  of  a  very  pale  color.  She 
has  not  had  her  attention  drawn  to 
any  coincidence  between  the  disap- 
pearance of  the  tumor  and  the  large 
amount  of  urine. 

Her  bowels  are  regular,  appetite 
good,  but  she  has  been  sleeping  badly 
of  late,  owing  in  part  to  the  worry 
about  the  tumor. 

Present    Condition. — Well -nour- 
ished, healthy -looking  woman  of  me- 
dium height.      The    abdomen    looks 
natural  ;     no     special    prominence. 
When  she  turns  a  little  on  the  right 
side  there  can  then  be  seen  a  projec- 
tion in  the  left  flank  just  above  the 
ilium,  and  between  the  tenth  rib  and 
the  anterior  spine  there  is  felt  a  promi- 
nent solid  mass,  which  above  lies  close  beneath  the  ribs,  while 
anteriorly  it  feels  superficial.     It  can  be  readily  grasped  between 
the  hands  and  moved  to  and  fro.     When  she  draws  a  deep  breath 
17 


Fig.  39.— Illustrating  the  position 
of  the  tumor  in  Case  LXI. 


172  THE  DIAGNOSIS  OF   ABDOMINAL  TUMORS. 

it  does  not  give  one  tlie  impression  of  coming  out  from  beneath 
the  ribs  and  is  not  much  depressed.  No  sharp  edge  can  be  felt, 
but  it  is  everywhere  rounded  in  outline. 

Percussion  in  the  splenic  region  is  clear,  and  beneath  the  level 
of  the  eighth  rib  there  is  a  flat  tympany  in  midaxillary  line.  As 
she  turns  on  the  right  side  the  mass  comes  forward  and  produces  a 
bulging  beneath  the  skin.  It  is  tolerably  firm  and  elastic,  but 
fluctuation  can  not  be  obtained. 

The  edge  of  the  spleen  is  not  palpable ;  the  liver  dullness  is  not 
increased;  the  edge  can  not  be  felt.  The  right  kidney  is  just 
palpable  on  deep  inspiration.  Examination  of  the  thoracic  viscera 
is  negative. 

The  patient  was  requested  to  make  a  careful  estimation  of  the 
urine  each  day,  and  note  with  reference  to  the  presence  or  absence 
of  the  tumor. 

September  11th. — Dr.  Finney  reports  that  last  night  on  examin- 
ing the  abdomen  no  trace  of  the  tumor  could  be  felt. 

She  was  ordered  a  bandage  with  a  carefully  adapted  pad,  and 
asked  to  estimate  the  amount  of  urine,  which  she  only  did,  how- 
ever, for  about  a  week.  On  the  11th  the  amount  of  urine  was 
flve  pints  and  a  fifth ;  on  the  12th,  three  pints  and  a  half  ;  on  the 
13th,  four  pints  and  a  half ;  on  the  14th,  four  pints  and  a  half ;  on 
the  15th,  three  pints  and  a  half ;  on  the  16th,  two  pints  and  a  half. 
From  6  A.  M.  to  6  P.  M.  on  the  16th  she  felt  tired  and  weak,  and 
had  uncomfortable  sensations,  and  she  passed  at  this  time  not 
quite  a  pint.  At  11  P.  M.  on  the  16th  the  tumor  mass  was  quite 
evident,  projecting  prominently  between  the  ribs  and  the  hip.  It 
was  evident  throughout  th^  17th,  but  she  felt  very  much  better 
toward  the  afternoon,  but  was  inclined  to  cry  and  fret^  and  was  a 
good  deal  distressed  at  the  recurrence  of  the  mass.  On  the  18th 
it  had  disappeared  entirely.  The  sample  of  urine  examined  was 
clear,  specific  gravity  1*015,  and  contained  neither  albumin  nor 
tube  casts. 

Additional  Note. — I  saw  this  patient  last  on  January  8th.  She 
had  been  very  nervous  and  uneasy  about  herself.  The  tumor  was 
present,  though  not  so  large  as  when  first  seen.  Its  appearance 
and  disappearance  have  been  repeatedly  verified  by  Dr.  Finney. 

Case  LXII.  Attacks  of  Colic ;  Tumor  in  the  Left  Benal  Re- 


TUMORS  OF  THE  KIDNEY.  173 

gion  u'hich  Appears  and  Disappears. — Mrs.  A.,  aged  twenty-seven 
years,  bipara,  had  consulted  me  on  two  or  three  occasions  for  dys- 
pepsia. On  October  2d  she  came  complaining  of  a  lump  in  the  left 
side,  which  had  been  present  on  and  oflf  all  the  summer,  and  which 
sometimes  gave  her  a  great  deal  of  pain.  She  first  noticed  it  in 
May,  following  an  attack  of  colic  of  great  intensity.  A  few  days 
subsequently  she  noticed  that  there  was  a  lump  in  the  left  side, 
which,  however,  gradually  went  away.  Since  then  it  has  appeared 
and  disappeared  five  or  six  times,  at  intervals  of  a  week  or  two, 
usually  developing  with  an  attack  of  pain,  which  gradually  sub- 
sides as  the  tumor  becomes  apparent.  No  special  uneasiness 
attends  its  disappearance,  and  she  has  not  noticed  any  special 
increase  in  the  amount  of  urine. 

Her  general  condition  has  kept  very  good;  she  has  gained  in 
weight,  and  the  old  dyspeptic  symptoms  for  which  I  saw  her  last 
year  have  almost  entirely  disappeared.  , 

She  is  a  medium-sized,  fairly  well  nourished  woman ;  color  of 
lips  good.     Pulse  80 ;  no  fever. 

The  abdomen  looks  natural ;  skin  not  very  much  scarred ;  only 
a  moderate  amount  of  panniculus.  A  prominence  can  be  seen  in 
the  left  flank.  On  quiet  breathing,  below  the  left  costal  border, 
in  the  position  of  the  edge  of  an  enlarged  spleen,  there  is  a  round- 
ed, superficial  mass,  which  descends  with  inspiration,  reaching 
fully  three  fingers'  breadth  from  the  margin.  It  passes  deeply  in 
the  region  of  the  kidney,  and  the  fijigers  can  be  inserted  between 
it  and  the  costal  margin.  Pressure  from  behind  in  the  left  flank 
pushes  the  mass  forward  so  as  to  elevate  the  skin  to  the  left  of  the 
navel.  When  very  large  she  says  it  reaches  quite  as  far  as  the 
middle  line.  The  lower  end  is  rounded,  but  without  any  marked 
prominence ;  it  is  movable  when  grasped  between  the  hands.  The 
splenic  dullness  can  not  be  obtained,  nor  is  an  edge  to  be  felt. 
The  percussion  over  the  tumor  mass  is  flat.  When  lying  on  the 
left  side  it  falls  down  somewhat,  and  the  fingers  can  be  passed 
freely  beneath  it.  There  is  no  uterine  or  ovarian  trouble,  and  the 
tumor  mass  does  not  appear  to  pass  toward  the  pelvis.  The  liver 
is  not  enlarged ;  there  is  no  dilatation  of  the  stomach, 

October  7th. — The  mass  is  stated  to  have  been  absent  for  three 
days. 


174 


THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS 


Examination.  —Fingers  can  be  passed  deeply  at  the  left  costal 
margin  without  meeting  anything.  The  kidney  is  readily  palpa- 
ble and  descends   with  inspiration.     She  passed  three  pints  and 

three  quarters  of  urine  during  the  three 
days  after  the  last  examination  ;  then 
on  Thursday  and  Friday  the  lump  had 
disappeared,  and  there  were  three  pints 
and  a  quarter,  so  that  the  difference  is 
not  very  great. 

The  attack  in  which  I  first  saw  the 
patient  came  on  Sunday,  October  1st, 
with  moderately  severe  pain,  and  dur- 
ing the  night  the  "  lump "  was  felt. 
She  states  that  it  was  not  so  prominent 
as  it  has  frequently  been.  Twice  the 
mass  has  extended  as  far  as  the  middle 
line. 

The  urine  was  examined  repeatedly. 
It  was  light  in  color;  specific  gravity 
never  above  1"020,  acid  in  reaction,  and 
contained  no  albumin  or  abnormal  in- 
gredients. There  were  no  differences 
between  the  urine  when  the  tumor  was  present  and  that  passed 
during  the  time  of  disappearance  of  the  mass. 

Throughout  November  the  patient  was  very  well.  A  carefully 
adapted  pad  and  bandage  have  given  her  great  relief,  and  she  has 
noticed  the  tumor  only  once.  She  has  been  in  Philadelphia  stay- 
ing with  friends.  Throughout  the  week  ending  December  16th 
she  had  had  a  great  deal  of  worry  and  trouble  with  illness  in  the 
family,  and  had  been  on  her  feet  a  great  deal.  On  the  15th  she 
was  tired  out  and  went  to  bed.  Stayed  in  bed  all  day  and  had 
some  pain  and  distress  on  the  left  side  and  noticed  the  reappear- 
ance of  the  tumor. 

December  16th. — To-day,  at  4.30  p.  m.,  the  tumor  mass  is  present, 
though  not  so  prominent  as  on  the  former  examination.  It  does 
not  reach  beyond  the  parasternal  line ;  is  not  specially  sensitive ; 
easily  moved  on  bimanual  palpation.  On  deep  inspiration  the 
fingers  can  be  placed  well  above  it. 


Fig.  40. 


-Position  of  the  tumor  in 
Case  LXU. 


TUxMORS  OF  THE  KIDNEY.  175 

On  questioning  the  patient  with  reference  to  the  onset  of  the 
attacks,  she  states  that  even  when  a  young  girl  she  remembers  to 
have  had  pain  in  the  left  side  after  running  or  after  dancing  for  a 
long  time,  but  she  never  noticed  the  presence  of  the  lump  until 
May  of  this  year.  She  has  given  up  measuring  the  daily  amount 
of  urine,  but  she  is  certain  that  there  is  no  striking  and  sudden  in- 
crease in  the  amount  as  the  tumor  disappears. 

Case  LXIII.  Pains  in  Left  Side,  with  Development  of  Tumoi\ 
which  gradually  Disappears. — Mrs.  X.,  aged  forty-six  years,  ad- 
mitted to  Ward  C,  October  23d,  complaining  of  intermittent  attacks 
of  pain  in  the  left  side,  and  a  swelling  or  lump  which  occurs  at  the 
same  time. 

The  family  history  is  good.  She  was  always  very  strong  as  a 
girl ;  married  at  twenty-two;  has  had  three  children,  the  youngest 
now  ten  years  old.  Was  never  very  large  during  her  pregnancies. 
Has  been  always  regular;  has  no  uterine  disease;  still  menstruates. 
Of  late  years  she  has  had  a  good  deal  of  mental  worry  and 
trouble,  and  has  had  a  very  busy  life,  actively  engaged  in  house- 
work. 

The  attacks  of  which  she  complains  date  as  far  back  as  eight  or 
nine  years  ago,  and  consisted  then  of  pain  in  the  left  side  occurring 
once  in  one  or  two  months,  which  was,  however,  quite  bearable. 
It  sometimes  followed  imprudence  in  diet;  sometimes  after  a  jolt- 
ing ride.  The  worst  attack,  shortly  after  the  trouble  began,  fol- 
lowed a  day's  journey  on  the  railroad.  The  pains  were  never  so 
severe  as  to  require  morphine,  but  there  was  a  sensation  of  uneasi- 
ness and  of  discomfort  and  aching  in  the  left  side.  Nearly  four 
years  ago  she  first  noticed  a  swelling  beneath  the  ribs  on  the  left 
side.  It  was  not  large  and  usually  only  lasted  a  day  or  two.  She 
can  always  tell  for  twenty-four  hours  before  an  attack  comes  on 
from  curious  dull,  heavy  feelings  all  over  her,  and  then  the  back- 
ache and  dragging  sensation  in  the  left  flank  begin.  Within  the 
past  year  or  so  the  attacks  have  been  more  frequent,  and  not  a 
month  has  passed  without  them.  The  lump,  too,  has  become  more 
prominent  during  the  attacks.  Lately  they  have  recurred  as  often 
as  every  week,  and  for  the  past  month  they  have  begun  regularly  on 
Sunday.  She  does  not  think  that  any  special  diet  brings  them  on, 
nor  has  she  noticed  lately  that  exercise  or  jolting  has  any  influence. 


176 


THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 


The  urine  has  been  clear ;  she  has  not  noticed  any  special  difficulty, 
nor  has  she  had  any  trouble  in  micturition.  The  bowels  are  some- 
times constipated,  and  more  particularly  at  the  time  of  the  attacks. 
Patient  is  thin,  weighs  only  one  hundi'ed  and  five  pounds,  and 
is  pale.  The  following  note  was  made  at  noon  of  October  24th  : 
The  abdomen  is  flat — not  specially  scarred.  On  palpation  it  is 
everywhere  soft  until  toward  the  left  costal  margin,  where  a  large 
mass  can  be  felt  occupying  the  left  side  of  the  abdomen,  and  project- 
ing apparently  from  beneath  the  ribs.  Anteriorly  it  extends  into 
the  umbilical  and  epigastric  regions  as  far  as  the  middle  line.  The 
lower  margin,  rounded  and  smooth,  is  nearly  at  the  level  of  the  an- 
terior superior  spine.  At  first  it  was  thought  possible  from  its  situ- 
ation to  be  an  enlarged  and  somewhat  irregular  spleen.  It  descends 
with  inspiration,  and  during  the  deepest  breath  the  hand  can  be 

passed  over  it,  and  the  mass  in  this 
way  held  down.  It  can  readily  be  felt 
from  behind,  and  on  bimanual  pal- 
pation can  be  grasped  between  the 
hands,  and  on  firmest  pressure  be- 
low the  ribs  behind  the  mass  can  be 
pushed  forward  so  as  to  lift  distinctly 
the  abdominal  wall.  The  lower  and 
posterior  surfaces  appear  to  be  irreg- 
ular. The  sensation  given  on  deep 
pressure  is  of  an  elastic  resistance. 
On  percussion  there  is  tympany  over 
the  mass  in  front,  a  flat  tympany  in 
the  raidaxillary  line,  and  dullness  be- 
hind. The  right  kidney  is  distinctly 
palpable  and  descends  far  enough  on 
inspiration  to  be  held  down.  For  the 
first  twenty  hours  in  hospital  patient 
passed  only  380  c.  c.  of  urine,  clear, 
straw-colored;  specific  gravity,  1"006;  slight  trace  of  albumin;  no 
sugar;  a  few  leucocytes,  and  flakes  of  epithelium. 

Patient  menstruated  from  the  25th  to  the  28th.  The  tumor  mass 
was  present  on  the  25th ;  no  examination  was  made  on  the  26th. 
On  the  27th  the  tumor  had  disappeared  entirely.     The  abdominal 


FiQ.  41.— Position    of    the    tumor 
mass  in  Case  LXTII. 


TUMORS  OP  THE  KIDNEY.  177 

walls  were  so  relaxed  that  palpation  could  be  freely  and  thoroughly 
made.  The  left  kidney  could  be  felt  on  deep  palpation.  It  did  not 
appear  to  be  in  any  way  enlarged ;  it  felt,  in  fact,  rather  small  and 
round.  A  daily  note  was  then  made  on  the  patient  and  the  urine 
carefully  measured.  The  patient  says  she  can  always  tell  a  day  or 
so  before  the  attack  comes  on  by  feeling  dull  and  the  onset  of  back- 
ache. 

From  October  28th  to  November  6th  the  daily  note  with  refer- 
ence to  the  left  kidney  was  negative.  It  was  felt  every  day.  She 
seemed  to  be  doing  very  well;  gained  in  weight,  and  had  not  so 
much  tenderness. 

November  7th. — Last  night  patient  had  a  heavy  feeling  in  the 
abdomen  after  eating,  and  a  little  distress  in  the  back,  as  if  an  attack 
might  be  coming  on.  This  morning,  however,  she  felt  well  again 
got  up,  went  to  town  on  a  street  car,  walked  about  a  good  deal. 
On  her  return  after  dinner  the  usual  symptoms  ushering  in  an  at- 
tack appeared — slight  headache  and  feeling  of  sluggishness,  and  a 
dull,  gnawing  ache  in  the  left  side,  with  a  feeling  of  fullness. 
Patient  expresses  it  that  she  is  entirely  "  taken  possession  of  by  the 
occurrence,"  is  listless,  and  if  it  comes  on  while  she  is  up  and  about 
her  knees  tremble  under  her  and  she  feels  that  she  must  lie  down. 
She  never,  however,  is  nauseated  or  sick  at  the  stomach. 

An  examination  was  made  at  11.30  A.  M.  on  the  6th,  and  the  fol- 
lowing note  dictated  :  "  On  drawing  a  deep  breath  the  left  kidney 
feels  a  little  larger  and  more  prominent  than  previously,  but  is  not 
tender."  To-day  (7th)  the  examination  was  made  at  3  p.  M.  The 
abdomen  is  slightly  distended ;  the  left  side  more  prominent  than 
the  right.  The  tumor  mass  previously  existing  again  occupies  the 
entire  left  flank,  extending  anteriorly  almost  to  the  level  of  the 
umbilicus.  The  anterior  border  is  hard,  somewhat  abruptly  defined, 
and  a  depression  can  be  felt  along  the  margin.  On  deep  inspira- 
tion the  mass  descends,  the  lower  end  almost  reaching  the  anterior 
superior  spine.  During  the  deepest  inspiration  the  fingers  can  be 
passed  above  its  upper  margin,  and  the  tumor  can  be  held  entirely 
below  the  level  of  the  tenth  rib.  From  behind,  the  postero-lateral 
surface  of  the  tumor  is  somewhat  irregular.  With  the  right 
hand  in  the  renal  region  behind  it  can  be  readily  pushed  forward 
so  as  to  cause  a  prominent  bulging  in  the  left  half  of  the  umbil- 


178  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

ical  region.  The  right  kidney  is  readily  palpable  and  presents  no 
change. 

8th. — The  tumor  mass  is  not  nearly  so  large  this  morning.  It  is 
firm,  rounded,  readily  palpable  between  the  two  hands,  and  is  still 
large  enough  to  be  made  to  project  beneath  the  skin  when  lifted 
from  behind.  She  says  she  has  not  nearly  so  much  uneasiness  and 
distress  in  the  side  to-day. 

9th. — The  mass  is  smaller  than  yesterday.    She  has  now  no  pain. 

10th. — The  tumor  has  disappeared.  The  left  kidney  is  readily 
palpated;  feels  smaller  than  the  right.  A  careful  estimate  was 
made  of  the  quantity  of  the  urine  each  day,  and  the  total  solids,  the 
reaction,  and  the  specific  gravity.  From  the  28th  of  October  to  the 
7th  of  November,  during  which  time  there  was  no  tumor,  the 
amount  of  urine  ranged  from  1,000  to  1,900  c.  c.  For  the  twenty- 
four  hours  ending  November  7th  the  amount  was  1,900  c.  c.  On 
the  8th  there  was  only  1,100  c.  c. ;  on  the  9th,  820  c.  c. ;  on  the  10th, 
1,200  c.  0. ;  on  the  11th,  1,210  c.  c. ;  on  the  12th,  980  c.  c.  The  urine 
has  always  been  clear,  is  usually  acid;  the  specific  gravity  ranges 
from  I'OIO  to  1'017;  generally  yellow,  straw-colored,  and  contains  a 
few  leucocytes.  There  was  no  special  change  in  its  appearance  or 
microscopical  characters,  either  on  the  7th,  8th,  or  9th,  when  the 
tumor  was  present,  or  the  10th,  11th,  and  12th,  after  it  had  disap- 
peared. The  patient  went  to  her  home  on  the  11th.  She  had  sub- 
sequently kept  account  of  the  amount  of  urine,  which  has  ranged 
from  two  and  a  half  to  five  pints  daily.  She  had  an  attack  in 
which  the  tumor  was  present  on  the  17th  and  18th,  on  which  days 
she  passed  two  and  a  half  and  three  pints  of  urine,  and  on  the  19th, 
20th,  and  21st  there  were  only  two,  three,  and  three  pints.  On  De- 
cember 1st  and  2d  there  was  again  an  attack  with  the  tumor  pres- 
ent. The  amount  of  urine  was  three  pints  on  both  days,  and  on 
the  3d,  4th,  and  5th  it  was  three,  three,  and  five  pints. 

December  16th. — This  patient  was  seen  last  to-day.  She  has 
been  better  in  many  ways,  but  for  the  past  week  has  not  been  feel- 
ing at  all  strong,  and  has  been  very  nervous.  The  tumor  has  been 
present,  she  states,  for  about  two  days.  On  examination  the  tumor 
mass  was  distinct,  though  small  in  comparison  with  the  previous 
notes.  It  extended  as  far  forward  as  the  parasternal  line,  and 
could  be  readily  moved  on  bimanual  palpation.     On  deep  inspira- 


TUMORS  OF  THE  KIDNEY.  179 

tion  the  fingers  could  be  pressed  above  it,  and  it  can  be  held  down. 
It  was  distinctly  lobulated.  In  the  anterior  axillary  line  it  felt 
superficial,  and  it  could  be  made  to  bulge  beneath  the  skin. 

A  carefully  adapted  pad  and  bandage  have  given  much  relief, 
and  the  attacks  have  not  recurred  so  frequently.  She  has  also 
gained  in  weight  and  is  in  every  way  better. 

Additional  Note,  February  17,  1894. — She  has  been  very  much 
better  since  last  note,  and  has  only  had  three  attacks ;  one  severe, 
requiring  opium.  In  all  three  the  tumor  mass,  however,  was  pres- 
ent. There  has  been  no  attack  for  four  weeks,  the  longest  intermis- 
sion which  she  has  had  for  months.  Her  appetite  is  good,  and  she 
now  weighs  one  hundred  and  twenty-two  pounds. 

These  cases  have  the  following  points  in  common :  The 
patients  have  borne  children ;  there  have  been  attacks  of 
colic-like  pain  in  the  left  side,  during  which  a  tumor  de- 
velops, to  disappear  in  the  course  of  a  few  days,  sometimes 
with  an  increase  in  the  amount  of  urine.  The  diagnosis 
seems  perfectly  clear.  There  is  no  other  condition  in 
which  a  tumor  in  the  flank  appears  and  disappears  in  this 
way.  Intermittent  hydronephrosis,  as  is  well  known,  con- 
stitutes the  most  remarkable  form  of  phantom  tumor ;  to- 
day you  may  find  the  side  of  the  abdomen  occupied  by  a 
large,  firm  mass  which  you  can  grasp  between  the  hands, 
and  which  may  be  so  prominent  as,  when  pressed  forward, 
to  lift  the  skin  of  the  abdomen  in  the  region  of  the  navel, 
and  to-morrow  you  may  be  completely  nonplussed  to  find 
that  the  tumor  has  disappeared,  leaving  not  a  trace  behind. 
There  are  remarkable  crises  in  which  this  history  repeats 
itself  throughout  a  series  of  years,  as  in  the  case  of  con- 
genital hydronephrosis  to  which  I  referred — a  young  man, 
aged  twenty-one  years,  who  had  had  from  his  second  year 
the  intermittent  development  of  an  enormous  abdominal 
tumor  which  disappeared  with  the  passage  of  a  large  quan- 
tity of  urine. 

The  subject  is  one  to  which  much  attention  has  been 
18 


180  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

given  of  late,  and  you  will  find  in  the  monograph  of 
Landau,  and  in  the  works  of  Morris  and  Newman,  excel- 
lent descriptions  of  intermittent  hydronephrosis.  The 
whole  question  has  been  most  thoroughly  considered  in 
the  monograph  which  I  here  show  you,*  in  which  the 
authors  have  collected  from  the  literature  seventy  cases.  I 
see  that  there  has  been  published  recently  in  London  a 
brochure  on  the  subject  by  Knight,  which  has  not  yet 
reached  me. 

A  large  proportion  of  all  the  cases  are  in  women,  who 
are  the  subject  of  it  at  least  four  times  more  frequently 
than  men,  in  about  the  same  proportion  as  they  are  more 
liable  to  movable  kidney.  The  left  side  is  more  frequently 
affected  than  the  right.  Of  forty-nine  cases  in  the  list  of 
Terrier  and  Baudouin  available  for  analysis  on  this  point, 
thirty  were  on  the  left  side  and  nineteen  on  the  right. 

The  general  symptoms  of  intermittent  hydronephrosis 
you  have  gathered  from  the  report  of  the  cases.  In  the 
intervals  the  patient  may  feel  perfectly  well,  or  may  have 
only  the  mental  worry  consequent  upon  the  uncertainty  of 
the  nature  of  the  trouble.  From  this  cause  Case  LXIII 
lost  rapidly  in  flesh.  Case  LXI  suffers  much  with  the 
nervous  features  so  often  associated  with  enteroptosis.  As 
a  rule,  and  this  is  an  important  point  in  the  diagnosis,  the 
health  is  good,  and  the  patients  are  very  comfortable,  ex- 
periencing only,  perhaps,  a  sense  of  weight  or  dragging  in 
the  side,  more  rarely  local  or  radiating  pains.  The  exami- 
nation of  the  side  may  be  negative ;  more  commonly 
there  is  a  movable  kidney,  sometimes  feeling  quite  normal, 
but  it  may  feel  small,  as  in  Case  LXIII,  or  swollen,  large 
and  tender.  There  are  instances  also  in  which  a  sac  may 
be  felt,  presenting  indurated  areas,  or  it  may  be  partly 
filled.    The  urine  is  clear  and   presents  usually  no   ab- 

*  De  Vhydronephrose  intermittente,  par  Felix  Terrier  et  Marcel  Baudouin. 
Paris,  1891. 


TUMOES  OP  THE  KIDNEY.  igl 

normal  ingredients;  in   some  cases  there  is  a  slight  tur- 
bidity from  pyelitis. 

You  will  have  noticed  in  the  reports  that  the  attacks 
recur  with  variable  frequency.  Among  the  circumstances 
liable  to  cause  them  are  sudden  and  violent  exercise,  the 
jarring  and  jolting  of  riding  and  driving,  any  fatigue, 
mental  emotions,  and  errors  in  diet.  In  Case.  LXIII  the 
patient  assured  us  that  she  could  at  any  time  bring  on  an 
attack  by  a  ride  in  a  jolting  street  car.  It  is  important  to 
bear  in  mind  that  indiscretions  in  eating  may  cause  them. 
The  patient  of  Dr.  Palmer  Howard's  could  at  any  time 
bring  on  a  severe  renal  crisis  by  taking  a  heavy  supper 
and  a  bottle  of  Bass's  ale.  The  onset  is  usually  manifest 
to  the  patient  by  pain  and  uneasiness  in  the  affected  side 
and  general  restlessness.  In  Case  LXIII  the  patient  knew 
at  once  when  the  tumor  was  developing  by  the  gnawing 
ache  in  the  left  side,  the  slight  headache,  and  the  feeling  of 
sluggishness.  The  attack  may  have  the  severity  of  nephri- 
tic colic  and  require  morphine  for  its  relief.  There  is  rarely 
fever,  nor  do  I  see  any  cases  reported  with  recurring  chills, 
the  absence  of  which  is  somewhat  remarkable,  considering 
their  frequency  in  affections  of  the  pelvis  of  the  kidney. 
Nausea,  vomiting,  diarrhoea,  and  distention  of  the  abdomen 
may  be  present.  The  attack  may  last  from  a  few  hours  to 
the  greater  part  of  a  day ;  the  pain  gradually  passes  away, 
and  the  patient  feels  only  a  soreness  and  heaviness  in  the 
side.  The  tumor  gradually  develops  during  the  attack, 
and  may  increase  in  size  for  several  days  after  the  inten- 
sity of  the  pain  has  subsided.  The  three  patients  who  have 
been  under  observation  had  learned  to  recognize  the 
tumor,  and  knew  at  once  when  it  was  present.  In  the 
frequent  examinations  which  I  have  made  of  Cases  LXII 
and  LXIII  I  never  found  them  in  error  on  this  point. 

The  tumor  itself  offers  no  characters  which  would  call 
attention  to  the  existence  of  intermittent  hydronephrosis. 


182  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

It  has  the  situation  and  relations  of  a  kidney  tumor,  with 
perhaps  a  greater  mobility  than  usually  met  with  in  neo- 
plasms or  pyonephrosis.  When  small,  it  may  be  very 
mobile,  and  some  have  detected  a  difference  between  the 
renal  and  the  pelvic  portions  of  the  sac,  separated  by  a 
groove.  It  is  deeply  placed,  rounded,  and  from  behind 
can  be  lifted  forward  from  its  bed.  The  median  and  lower 
surfaces  are  smooth,  sometimes  irregular,  but  there  is  no 
sharp  margin  or  rounded  edge.  Pressure  is  often  pain- 
ful, and  causes  at  times  an  urgent  desire  to  urinate. 
Fluctuation  is  rarely  obtained,  but  there  is  often  a  sense  of 
elastic  resistance.  The  colon,  small  bowel,  and  part  of  the 
stomach  usually  lie  in  front  of  the  tumor  and  mask  the 
percussion  in  the  outer  half  of  the  umbilical  region  or  in 
part  of  the  flank. 

During  the  existence  of  the  tumor  the  amount  of  urine 
passed  is,  as  a  rule,  greatly  diminished.  After  persisting 
for  a  variable  time  the  tumor  may  disappear  suddenly 
with  the  greatest  relief  to  the  patient,  and  when  the  evac- 
uation is  rapid  there  is  always  a  notable  increase  in  the 
quantity  of  urine.  In  not  one  of  the  three  cases  which 
we  have  considered  was  the  discharge  brusque,  as  in 
some  instances  which  are  on  record,  but  the  disappear- 
ance of  the  tumor  was  gradual,  and  the  increase  in  the 
amount  of  urine,  though  noted  in  two  of  them,  was  not 
striking. 

With  the  disappearance  of  the  tumor  the  patient  again 
becomes  quite  comfortable,  and  may  remain  so  for  weeks 
or  even  months  without  a  recurrence  of  the  attack. 

The  recognition  of  the  condition,  when  fully  estab- 
lished, is  comparatively  easy.  The  pains,  the  development 
of  a  tumor  in  the  flank,  its  disappearance,  usually  with  an 
increase  in  the  amount  of  urine,  form  a  symptom  group 
sufficiently  characteristic.  It  is  by  no  means  so  easy  to 
determine  always  the  cause.     Some  of  the  cases,  as  already 


TUMORS  OF  THE  KIDNEY.  183 

mentioned,  are  congenital,  and  have  persisted  for  years. 
Terrier  and  Baudouin  divide  the  cases  of  acquired  inter- 
mittent hydronephrosis  into  those  in  which  the  cause  is 
obscure  or  ill-determined,  the  cases  due  to  lesion  of  the 
bladder  or  of  the  parts  in  the  vicinity  of  the  lower  end  of 
the  ureter,  and  the  cases  associated  with  displaced  or 
movable  kidney,  and  due  to  lesions  in  the  upper  extremity 
of  the  ureter.  In  the  first  group  there  are  a  certain  num- 
ber of  cases  in  which  the  intermittent  hydronephrosis  is 
due  to  calculus.  There  are  instances  also  caused  by  blood 
clots,  by  tuberculous  lesions,  and  by  spasm  of  the  ureter. 
In  the  second  group  of  cases  the  lesion  of  the  bladder  is 
most  commonly  tumor,  with  infiltration  of  the  wall  near 
the  orifice  of  the  ureter,  and  by  lesions  of  the  uterus  and 
vagina,  particularly  cancer. 

The  important  role  in  intermittent  hydronephrosis  is 
unquestionably  movable  kidney,  the  association  with 
which  has  been  recognized  since  the  publication  of  Lan- 
dau's monograph  in  1881.  You  will  find  in  the  work  of 
Terrier  and  Baudouin  the  records  of  the  autopsies  which 
have  been  made,  and  of  the  examinations  of  the  kidneys 
which  have  been  removed  by  operation,  and  I  show  you 
here  several  of  the  figures  which  illustrate  the  marked 
kinking  at  the  upper  part  of  the  ureter.  In  other  in- 
stances the  ureter  has  penetrated  the  pelvis  at  a  very 
acute  angle ;  and  in  other  cases,  again,  there  appears  to 
have  been  a  positive  flexion  or  twist.  It  is  not  difficult  to 
understand  how,  in  the  displacement  of  the  organ,  such  a 
flexion  or  kinking  could  occur,  and  the  wonder,  indeed,  is 
that  it  does  not  occur  more  commonly. 

You  will  naturally  ask.  What  becomes  of  these  cases  ? 
It  is  quite  possible  that  the  condition  may  be  transient, 
even  when  associated  with  movable  kidney.  The  careful 
adaptation  of  a  bandage  and  pad  may  give  great  relief,  as 
in  Case  LXIII ;  also  in  case  LXII  to  a  less  degree.    When 


184 


THE  DIAGNOSIS  OF  ABDOMINAL  TUMOES. 


the  attacks  are  severe  and  the  tumor  recurs  with  fre- 
quency, nephrorrhaphy  should  be  urged.  The  chief  dan- 
gers are  the  conversion  of  an  intermittent  into  a  perma- 
nent hydronephrosis,  and  the  infection  of  the  sac  with 
pyogenic  organisms — conditions  which  demand  operative 
interference.  It  is  interesting  to  note,  however,  the  pro- 
longed period  during  which  the  contents  of  the  sac  re- 
main clear.  In  the  congenital  case  of  twenty  years'  dura- 
tion, to  which  I  have  so  frequently  referred,  the  secretion 
of  the  affected  kidney — dilated  to  a  shell,  but  still  contain- 
ing renal  tissue — was  only  a  little  turbid. 

III.  Malignant  Disease.— Of  three  cases  which  came 
before  me  for  diagnosis,  two  were  in  children  under  the  age 
of  ten. 

Case  LXIV.  Gradual  Development  of  an  Enormous  Tumor 
in  Left  Side  of  Abdomen.— 'E>.  R.,  a  boy  of  ten  years,  seen  with 

Dr.  Hewetson,  May  10,  1893.  I  had 
seen  him  about  six  or  eight  months 
before  for  a  few  minutes  in  the  dis- 
pensary. Unfortunately,  the  notes 
made  at  that  time  have  been  mislaid. 
He  has  had  for  nearly  a  year  a  pro- 
gressively increasing  tumor  in  the 
left  side  of  the  abdomen.  Until  two 
months  ago  he  has  been  able  to  get 
about  by  himself,  but  he  is  now  so 
•weak  and  the  tumor  is  so  large  that 
he  is  scarcely  able  to  w^alk.  He  has 
become  very  much  emaciated,  and 
since  I  first  saw  him  the  tumor  has 
increased  greatly  in  size.  His  chief 
complaint  at  present  is  of  pain  down 
the  left  leg,  and  about  the  ankle 
and  hip  of  the  same  side.  The  ab- 
domen is  greatly  distended,  particularly  on  the  left  side,  and  the 
superficial  veins  are  very  full.  The  lower  part  of  the  thorax  on 
the  left  side  is  much  expanded,  and  the  costal  margin  averted. 


Fig.  42.- 


-Outline  of  the  tumor  in 
Case  LXIV. 


TUMORS  OF  THE  KIDNEY.  185 

Tlie  entire  left  half  of  the  abdomen  is  occupied  by  a  solid  mass, 
which  extends  from  the  ribs  to  the  pubes,  and  is  extremely  firm 
and  immobile.  The  surface  is  smooth,  except  toward  the  lower 
and  right  margins,  where  it  is  irregular.  Percussion  over  it  is 
everywhere  flat.  It  extends  upward  as  far  as  the  seventh  rib,  and 
behind  to  the  angle  of  the  scapula.  Just  above  the  anterior  supe- 
rior spine  of  the  ilium  there  is  a  prominent  bulging.  The  inguinal 
glands  are  enlarged  and  hard,  and  the  supraclavicular  glands  on 
the  left  side  are  also  slightly  enlarged.  The  left  leg  is  slightly 
swollen,  and  the  veins  are  enlarged  and  prominent,  as  are  also  the 
veins  over  the  flank  and  buttocks.  There  have  never  been  any 
urinary  symptoms;  he  has  not  passed  any  blood,  but  he  has  had 
pain  lately  owing  to  pressure  upon  the  nerves  and  veins  in  the 
left  side  of  the  pelvis. 

Case  LXV.  Large  Tumor  in  Left  Side  of  Abdomen ;  Haema- 
tiiria;  Removal  of  Sarcomatous  Kidney;  Recovery. — Minnie  H,, 
aged  five  years,  admitted  to  Ward  G  from  the  dispensary,  Janu- 
ary 18,  1893,  with  tumor  in  the  abdomen,  which  the  mother  said 
had  been  noticed  for  several  months.  She  had  been  failing  in 
health,  losing  weight,  and  on  several  occasions  had  passed  blood  La 
the  urine. 

Present  Condition. — Not  greatly  emaciated ;  not  particularly 
anaemic.  Veins  look  blue  and  the  blood  a  little  watery.  She 
has  had  no  fever;  pulse  quiet.  Abdomen  greatly  distended,  nu- 
symmetrical;  the  greatest  prominence  is  in  the  hypogastric,  um- 
bilical, and  left  inguinal  regions.  The  whole  of  the  left  side  is 
fuller  and  larger  than  the  right,  and  does  not  display  the  re- 
spiratory movements.  The  superficial  epigastric  and  mammary 
veins  are  much  distended.  There  are  two  prominences  to  the  left 
of  the  navel,  and  one,  less  prominent,  seven  centimetres  below  the 
costal  margin  in  the  left  nipple  line.  There  is  a  fourth  just  at  the 
tip  of  the  eleventh  rib  in  the  left  flank.  On  palpation,  the  greater 
portion  of  the  abdomen  is  occupied  by  a  firm,  solid  growth,  which 
fills  completely  the  left  half,  extends  fully  five  centimetres  beyond 
the  middle  line,  and  fills  the  greater  portion  of  the  hypogastric 
region.  In  the  left  half  of  the  epigastric  region  it  is  covered 
with  stomach  or  bowel  and  is  not  so  prominent,  and  can  only  be 
felt  on  deep  pressure.     It  passes  under  the  costal  margin  of  the 


186 


THE  DIAGNOSIS  OP  ABDOMINAL  TUMORS. 


seventh  rib.     It  is  extremely  firm,  resistant,  not  very  movable  on 
bimanual  palpation,  and  not  sensitive.    It  fills  the  entire  flank,  and 

behind  is  superficial, 
and  gives  the  impres- 
sion of  occupying  close- 
ly the  whole  lumbar  re- 
gion. The  surface  is 
irregular,  and  on  palpa- 
tion the  prominences 
referred  to  are  very  dis- 
tinct. In  the  right  iliac 
fossa  a  soft  mass  can  be 
felt,  which  is  probably 
the  colon  pushed  over, 
partly  adherent,  and  can 
be  felt  on  the  tumor 
mass.  Above,  as  already 
mentioned,  the  tumor  is 
covered  in  the  left  half 
of  the  epigastric  region 
by  stomach  and  intes- 
tines, and  there  is  a  soft, 
movable  mass,  which 
may  represent  the  curled 
and  thickened  omen- 
tum. 

I  will  read  to  you 
the  remarks  wliicli  I 
made  in  ward  class 
after  demonstrating 
this  child,  and  which 
I  find  here  with  the 
type  -  written  report 
of  the  case : 

"  In  children,  mas- 
not   uncommon,  and. 


Fig.  43.— Outline  of  the  tumor  mass  in  Case  LXTV. 


Five  tumors   of   the  abdomen   are 


as  a  rule,  are  either  sarcomata  of  the  kidney  or  of  the 


TUMORS  OF   THE   KIDNEY.  187 

retro-peritoneal  glands.  The  kidney  tumors  are  tlie  most 
frequent.  Both  ultimately  produce  large,  solid  growths, 
which  may  occupy  the  greater  portion  of  the  abdominal 
cavity.  In  the  differentiation  of  these  two  forms  we 
rarely  have  any  difficulty.  Both  develop  painlessly,  and 
the  child  may  make  no  complaint  whatever  ;  the  gen- 
eral health  may  not  be  seriously  affected,  even  when  the 
mass  has  attained  a  considerable  size.  Death,  indeed,  may 
occur,  as  in  a  remarkable  case  which  I  have  reported  of  em- 
bolism of  the  heart  (the  transference  of  sarcomatous  throm- 
bi from  the  renal  vein),  before  there  were  any  symptoms  to 
attract  attention.  Progressive  emaciation,  with  enlargement 
of  the  abdomen,  usually  painless,  as  in  the  case  of  this  child, 
are  the  prominent  characters,  which  are  common,  however, 
to  both  the  renal  and  the  retro-peritoneal  growth.  The  two 
important  points  of  differentiation  are,  first,  the  retro-peri- 
toneal growth  is  more  central  in  its  origin,  and,  if  seen 
early,  it  is  found  to  occupy  the  umbilical  region,  not  ex- 
tending to  the  flanks ;  whereas,  in  the  renal  tumor,  as  in 
the  case  before  us,  the  growth  is  lateral,  and  fills  the  entire 
flank,  extending  deeply  behind. 

"  The  kidney  tumor  is,  as  a  rule,  associated  with  changes 
in  the  condition  of  the  urine.  Blood  is  present,  either  as 
free  hsematuria,  or  the  constant  presence  of  a  small  number 
of  red  blood-corpuscles.  There  may  be  large  clots,  the 
passage  of  which  causes  great  pain.  In  some  cases  molds 
in  blood  of  the  pelvis  of  the  kidney  and  of  the  ureters  are 
passed,  though  this  is  not  so  common  in  children  as  in 
adults.  Other  conditions  which  have  to  be  differentiated 
are  ovarian  tumors,  pyonephrosis,  and  cysts,  but  in  cases 
of  doubt  the  exploratory  operation  should  be  strongly 
urged." 

The  tumor  in  this  case  was  removed  by  Dr.  Halsted  and 

found  to  be  an  enormous  sarcoma  of  the  kidney.     The 

operation  was  not  at  all  difficult,  the  child  made  an  unin- 
19 


188  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

termpted  recovery,  and  when  last  heard  of,  a  month  or 
two  ago,  remained  well. 

Case  LXVI.  Large  Tumor  in  the  Left  Side  of  the  Abdomen  ; 
Recurring  Hcematuria. — November  2,  1893.  I  saw  to-day,  with 
Dr.  Lilhan  Welch,  Mrs.  X.,  aged  sixty-three  years,  who  had  for 
many  months  a  progressively  enlarging  tumor  of  the  abdomen  with 
hsematuria.  Until  within  the  present  year  she  has  always  been  a 
very  healthy  woman.  She  has  been  gradually  faihng  in  strength, 
and  within  the  past  six  months  has  lost  a  great  deal  in  weight, 
and  lately  the  emaciation  has  become  very  great.  On  several  oc- 
casions during  the  past  four  months  she  has  passed  bloody  urine, 
and  only  at  these  times  has  she  had  any  pain. 

The  patient  is  a  small-framed,  much-emaciated  woman.  The  ab- 
domen is  distended,  particularly  on  the  left  side,  which  is  occupied 
in  its  whole  extent  by  a  large,  solid  tumor.  To  the  right  it  extends 
beyond  the  middle  line,  and  reaches  below  the  anterior  superior 
spine.  It  is  firm,  but  with  bimanual  palpation  it  can  be  moved 
slightly  from  side  to  side.  The  right  surface  and  lower  border  pre- 
sent large  irregularities.  It  is  everywhere  flat  on  percussion,  ex- 
cept at  the  right  border.  The  glands  are  not  enlarged;  the  super- 
ficial veins  are  only  slightly  prominent ;  the  examination  of  the 
other  organs  is  negative.  The  urine  at  the  time  of  my  examination 
was  clear.  At  intervals,  however,  she  has  passed  considerable 
quantities  of  blood,  and  on  these  occasions  there  has  been  a  good 
deal  of  pain.  Considering  the  solid  nature  of  the  growth,  the  oc- 
currence of  haematuria,  and  the  rapid  emaciation,  the  diagnosis  of 
malignant  disease  of  the  kidney  was  thought  to  be  quite  clear,  and 
it  was  not  deemed  advisable  to  put  her  to  the  pain  of  an  aspira- 
tion ;  nor  did  her  condition  seem  favorable  for  an  exploratory 
operation. 

The  patient  died  a  few  weeks  after  my  visit,  and  Dr. 
Welch  tells  me  that  the  post-mortem  showed  an  enormous 
new  growth  in  the  kidney,  with  small  secondary  nodules 
in  the  liver. 

There  are  two  points  which  you  must  ever  bear  in  mind 
in  the  diagnosis  of  large  tumors  in  the  flank :  first,  the  ira- 


TUMORS  OF  THE  KIDNEY.  189 

portance  of  thorough  and  systematic  examination  of  the 
urine  with  a  view  of  determining  the  presence  of  pus,  tu- 
bercle bacilli,  or  blood  ;  and,  secondly,  the  use  of  the  aspi- 
rator needle.  The  condition  which  is  really  most  apt  to 
cause  error  is  the  progressively  enlarging  kidney  of  pyo- 
nephrosis. Gynaecological  records  indicate  how  frequently 
this  tumor  leads  to  error,  but  the  chances  are  reduced  to  a 
minimum  if  attention  be  paid  to  the  two  points  I  have  just 
mentioned.  Catheterization  of  the  ureters  may  also  give 
information  of  the  greatest  value. 

IV.  Tuberculosis. — A  large  kidney  tumor  is  rarely 
due  to  tuberculosis  of  the  substance  of  the  organ,  but 
tuberculous  pyelitis  may  lead  to  considerable  enlargement 
of  the  pelvis  and  calices,  and  a  certain  number  of  all  cases 
of  pyonephrosis  have  this  origin.  The  tuberculous  kid- 
ney, however,  rarely  forms  a  large  abdominal  tumor.  The 
following  case  illustrates  two  important  features  in  the 
diagnosis  of  renal  tuberculosis ;  namely,  the  determination, 
by  catheterization  of  the  ureters,  that  the  pus  came  al- 
together from  one  side,  and  the  detection  of  tabercle  ba- 
cilli in  the  urinary  sediment. 

Case  LXVII.  Cough  for  Five  Years;  Pulmonary  Tubercu- 
losis; Enlargement  of  the  Right  Kidney;  Pyuria;  Tubercle- 
Bacilli  in  Urine. — Susan  S.,  aged  sixty -three  years,  admitted  June 
4,  1893,  complaining  of  pain  in  the  abdomen.  The  patient  was 
under  observation  for  a  few  days  in  September,  1890,  when  she  had 
slight  cough,  and  pus  and  albumin  in  the  urine,  hut  no  tubercle 
bacilli  were  found  at  that  time. 

The  patient's  mother  died  of  tuberculosis.  She  has  had  five 
children,  all  living  and  well.  She  had  pneumonia  when  thirty- 
five  years  of  age.  For  five  years  at  least  she  has  had  cough,  with 
slight  expectoration,  and  she  has  had  at  times  severe  chills,  which 
have  been  supposed  to  be  due  to  malaria. 

Lately  she  has  had  a  great  deal  of  pain  and  uneasiness  in  the 
abdomen,  and  has  been  under  treatment  for  cystitis,  though  she 
has  had  no  special  pain  in  passing  water. 


190  THE  DIAGNOSIS  OF  ABDOMINAL  TUMORS. 

Present  Condition. — Moderate  emaciation;  marked  patchy  pig- 
mentation on  the  face;  slight  anaemia;  no  fever;  pulse  92,  of  fair 
volume.  At  the  left  apex  the  percussion  is  a  little  higher  in  pitch, 
and  there  are  piping  and  moist  sounds  in  the  first  and  second 
spaces.  The  sputum  is  muco-purulent,  with  yellowish  lumps,  and 
in  these  a  few  tubercle  bacilli  are  found  ;  no  elastic  tissue. 

The  heart  sounds  are  clear. 

The  abdomen  is  flat,  soft,  no  pain  on  pressure.  The  right  kid- 
ney feels  two  or  three  times  as  large  as  a  normal  organ.  On 
deepest  inspiration  it  does  not  come  down  far  enough  for  the 
fingers  to  be  placed  above  it.  No  cord-like  mass  to  be  felt  in  the 
course  of  the  right  ureter.  The  left  kidney  is  not  palpable.  The 
urine  is  turbid,  light  yellow  in  color,  specific  gravity  from  1-007  to 
1"010,  and  on  settling  deposits  a  creamy  pus.  There  is  a  trace  of 
albumin,  and  one  or  two  granular  casts  are  found.  Many  exam- 
iaations  were  made  for  tubercle  bacilli.  At  first  none  were  found, 
but  subsequently  they  were  found  after  centrifugalizing  the  m-ine, 
and  once  in  considerable  numbers. 

On  July  12th,  under  chloroform  anaesthesia,  Dr.  Kelly  cathe- 
terized  the  ureters.  From  the  left  a  perfectly  clear  urine  flowed; 
from  the  right,  a  yellow-brown  pus,  in  which  tubercle  bacilli 
were  detected.  The  patient  had  very  slight  fever,  no  chill  while 
in  hospital,  and  appetite  and  general  condition  improved  very 
much. 

There  are  two  points  in  the  diagnosis  of  tuberculous 
pyelonephritis  which  are  well  illustrated  by  this  case. 
The  condition  is  very  frequently  mistaken  for  cystitis,  and 
in  men  more  frequently  than  in  women  there  is  great  fre- 
quency in  micturition  and  great  irritability  of  the  bladder, 
for  which  on  more  than  one  occasion  I  have  known  peri- 
neal section  to  be  performed.  The  urine,  however,  is  as  a 
rule  acid  in  tuberculous  pyelonephritis,  as  in  this  case,  un- 
less there  is  extensive  co-existing  tuberculous  cystitis. 
The  other  point  is  the  association  of  recurring  chills. 
You  will  have  noticed  in  the  history  that  this  patient  was 
supposed  to  have  malarial  disease  on  account  of  the  severe 


TUMORS  OF  THE  KIDNEY.  191 

chills  wlLich  occurred  at  intervals  during  tlie  past  five 
years.  They  may  form  a  very  special  feature  in  the  dis- 
ease, as  was  pointed  out  many  years  ago  by  Owen-Rees, 
and  it  is  to  be  remembered  that  the  chills  may  occur  with 
a  very  slight  amount  of  pus  in  the  urine. 

One  of  the  most  important  advances  in  the  diagnosis  of 
renal  affections  has  been  the  facility  with  which  of  late 
surgeons  have  practiced  catheterism  of  the  ureters.  Such 
a  demonstration  as  we  had  in  this  case  by  Dr.  Kelly— the 
catheters  in  position  in  both  ureters  at  once,  from  the  right 
of  which  a  turbid,  purulent  urine  flowed  out,  from  the  left 
a  perfectly  clear— illustrates  the  remarkable  technique 
which  has  been  developed  by  specialists.  The  demonstra- 
tions which  many  of  you  have  seen  in  the  genito-urinary 
department  by  Dr.  James  Brown  prove  that  catheterism  of 
the  male  ureters,  though  not  so  easy,  may  be  performed 
with  readiness,  and  gives  information  of  the  greatest  value 
as  to  which  kidney  is  involved. 

In  the  series  of  cases  which  we  have  studied  together 
you  have  had  many  illustrations  of  how  far  the  reasonable 
probability  of  Bishop  Butler  will  carry  the  clinical  physi- 
cian in  his  endeavors  to  determine  the  nature  of  an  ab- 
dominal tumor.  You  will  have  noticed  in  how  many  cases 
the  surgeon  made  it  a  certainty,  not,  unhappily,  in  diag- 
nosis only,  but  also  in  prognosis.  But  desperate  cases 
require  desperate  remedies,  and  in  no  single  instance  were 
the  chances  of  a  patient  damaged  by  the  exploratory  in- 
cision. 

Amid  many  pleasant  memories  of  Berlin,  just  twenty 
years  ago  this  session,  none  recur  more  persistently  than 
those  associated  with  that  true  Asclepiad,  Ludwig  Traube, 
who,  adding  probity  to  learning,  sagacity,  and  humanity, 
reached  the  full  stature  of  the  Hippocratean  physician. 
When  acknowledging  some  error  he  would  say — often  in  a 
soft,  meditative  manner,  as  if  gently  reproaching  himself — 


192  THE  DIAGNOSIS  OP  ABDOMINAL  TUMORS. 

Have  we  carefully  observed  all  the  facts  of  the  case  ?  Yes. 
Did  the  art  permit  of  a  judgment  on  the  facts  under  con- 
sideration ?  Yes.  Did  we  reason  correctly  upon  the  data 
before  us  ?  No.  Wir  haben  nicht  richtig  gedacht.  And 
with  these  significant  words — may  they  long  echo  in  your 
ears ! — let  us  close  the  exercises  of  the  session. 


THE    END, 


A  TEXT-BOOK  ON  SURGERY: 

GENERAL,    OPERATIVE,  AND  MECHANICAL. 
By  JOHN  A.    WYETH,  M.  D., 

ProfesBor  of  Surgery  in  the  New  York  Polyclinic ;    Surgeon  to  Mount  Sinai  Hospital,  etc 

THIRD  EDITION,  REVISED  AND  ENLARGED. 

997  pages,  with  938  Illustrations. 

Buckram,  uncut  edges,  $7.00 ;  sheep,  $8.00 ;  half  morocco,  $8.50. 

SOLD  ONLY  BY   SUBSCRIPTION. 


From  Author's  Preface. 

The  original  edition  of  this  work  was  published  in  1886.  It  was  revised  and 
enlarged  in  a  second  edition  in  1890.  Within  the  period  of  seven  years  to  this 
date  (November,  1897)  so  many  important  advances  have  been  made  in  surgical  sci- 
ence and  the  operative  technique  that  the  author  has  found  it  necessary  again  to 
revise  and  practically  rewrite  this  volume.  To  add  all  that  was  new  and  acceptable 
to  that  which  experience  had  already  demonstrated  to  be  useful  has  of  necessity 
increased  the  number  of  pages  and  size  of  the  book.  By  careful  elimination  of 
matter  which  could  with  least  disadvantage  be  left  out,  this  volume,  however,  only 
exceeds  the  former  by  one  hundred  and  twelve  pages. 

It  has  been  the  author's  aim  to  retain  those  features  of  the  original  work  which 
made  it  available  to  the  busy  practitioner  for  quick  and  ready  reference,  and  to  add 
to  this  edition  some  elementary  pages  which  may  commend  it  to  teachers  for  their 
undergraduate  pupils.  With  this  end  in  view  the  matter  has  in  great  part  been 
rearranged. 

The  introductory  section  is  devoted  to  surgical  pathology,  subdivided  into  six 
chapters.  These  chapters  treat  of  inflammation  and  the  process  of  repair  in  the 
various  tissues  of  the  body,  and  the  differences  in  repair  in  a  tissue  affected  with 
simple  or  non-infective  and  infective  (or  suppurative)  inflammation.  Specific  and 
non-specific  urethritis,  erysipelas,  actinomycosis,  glanders,  tetanus,  malignant 
cedfma,  hydrophobia,  tuberculosis,  syphilis,  leprosy,  diphtheria,  and  typhoid  infec- 
tion are  also  embraced  in  this  portion  of  the  work. 

Chapters  VII  and  VIII  are  devoted  to  surgical  dressings,  sterilization,  asepsis 
and  antisepsis,  and  anaesthesia. 

In  Chapters  IX  and  X  are  given  htemorrhage,  wounds,  burns,  skin  grafting, 
frostbite,  furuncle,  carbuncle,  ulcers,  and  gangrene.  Bandaging  is  given  in  Chap- 
ter XI,  and  Chapter  XII  is  devoted  entirely  to  amputations. 

Chapters  XIII,  XIV,  and  XV  deal  with  the  lymphatic  vessels  and  glands,  veins, 
arteries,  aneurism,  and  ligation  of  the  vessels. 

In  Chapters  XVI  and  XVII  are  given  the  lesions  of  the  bones  and  joints,  and 
the  various  operative  measures  for  their  correction. 

The  chapters  from  XVIII  to  XXIX  inclusive  are  devoted  to  regional  surgery, 
and  in  that  portion  of  this  section  in  which  the  abdomen  is  considered  many  im- 
portant changes  have  been  made  and  much  new  matter  added.  Chapter  XXX  takes 
up  deformities  and  their  correction,  while  the  final  chapter  (XXXI)  is  devoted  to 
the  subject  of  tumors. 

D.  APPLETON  AND   COMPANY,  NEW  YORK. 


THE   PRINCIPLES  AND   PRACTICE 
OF    MEDICINE. 

By  WILLIAM   OSLER,    M.  D., 

Fellow  of  the  Royal  College  of  Physicians,  London ;  Professor  of  Medicine  in  the  Johns  Hopkins  Univer- 
sity, and  Physician  in  Chief  of  the  Johns  Hopkins  Hospital,  Baltimore  ;  formerly  Professor  of 
the  Institutes  of  Medicine,  McGill  University,  Montreal;  and  Professor  of  Clinical 
Medicine  in  the  University  of  Pennsylvania,  Philadelphia. 


THE    WORK   HAS  BEEN  REWRITTEN,    ENLARGED,    ENTIRELY  RESET, 
AND  BROUGHT   UP   TO  DATE  IN  ALL  DEPARTMENTS. 


THIRD   EDITION. 
SOLD    ONLY    BY    SUBSCRIPTION. 


8vo,  1181  pages.     Cloth,  $5.50;   sheep,  $6.50;   half  morocco,  $7.00. 


' '  With  new  type,  clear  paper  of  the  best  quality,  and  a  somewhat  enlarged  page,  necessi- 
tated by  the  amount  of  matter  in  the  very  thorough  revision  of  a  book  whose  first  edition 
appeared  six  years  ago,  Osier's  Practice  comes  to  us  with  that  handsome  entourage  its  prime 
excellence,  merit,  and  true  value  demand.  .  .  .  From  first  to  last,  title-page  to  index,  the 
work  is  thoroughly  practical,  and  as  a  g^uide  in  diagnosis,  symptomatology,  and  treatment, 
will  be  found  well-nigh  incomparable,  and  can  not  but  be  the  more  appreciated  the  more  its 
sound  advice  and  wise  counsel  are  sought,  whether  by  the  neophyte  in  medicine  or  the  most 
experienced  clinician."^.S<?«i'//^r«  Practitioner. 

"  We  have  little  to  add  to  our  notice  of  the  second  edition  {vide  Journal,  November  30, 
1895,  page  g66).  The  criticisms  then  made  hold  good  now,  but  we  regarded  the  work  as  one 
of  the  ablest  contributions  to  the  literature  of  the  subject  in  this  country,  an  opinion  which 
we  still  hold." — Journal  of  the  American  Medical  Association. 

"  The  first  edition  was  great,  the  second  greater,  and  this  last  greatest  of  all." — Cincin- 
nati Lancet-Clinic. 

' '  There  are  few  books  which  receive  professional  confidence  and  esteem  to  the  extent  of 
that  received  by  Dr.  Osier's  well-known  work,  for  three  large  editions  have  been  presented  to 
us  in  a  period  of  about  six  years." — Therapeutic  Gazette. 

"  The  work,  like  former  editions,  is  thoroughly  practical  in  its  character,  fully  up  with  the 
times  and  down  to  date,  and  is  a  safe  guide  to  all  practitioners  who  may  consult  its  pages. 
The  student  of  medicine,  whose  time  is  so  much  occupied  by  the  tremendous  amount  of 
knowledge  he  is  expected  to  master  before  graduation,  will  find  here  exhaustiveness  without 
verbosity  and  a  plain  matter-of-fact  method  of  discussing  the  characters  of  different  diseases, 
that  can  not  fail  to  instruct  without  wearying." — Journal  of  Medicine  and  Science, 


D.   APPLETON   AND   COMPANY,   NEW   YORK. 


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